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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 59-69

Effect of an interpersonal problem solving intervention on problem solving skills and self-esteem in patients with schizophrenia


Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt

Date of Submission10-Apr-2019
Date of Acceptance13-May-2019
Date of Web Publication5-Dec-2019

Correspondence Address:
Souzan Abd El-Menem Abd El-Ghafar Harfush
Tanta, Al –Gehish street, Mogamaa El- Shamla, Lecturer of Psychiatric and Mental Health Nursing, Faculty of Nursing, Tanta university, Postal code: 31527
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_3_19

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  Abstract 


Background Effective interpersonal problem-solving skills have been identified as essential aspects for successful functioning in daily life and also for decreasing vulnerability to relapse. If patients with schizophrenia learn interpersonal problem - solving skills from a systematic method and successfully apply them in their daily life, the beliefs about their self- competence in handling interpersonal problems will develop and improve their self-esteem.
Aim The study aimed to determine the effect of an interpersonal problem solving intervention on problem solving skills and self-esteem in patients with schizophrenia. Research design; randomization control trial design was applied.
Setting The study was carried out in psychiatry, Neurology, Neurosurgery center that was affiliated to Tanta University, Egypt.
Subjects and method The participants of this study were forty patients with schizophrenia; they were divided randomly into control and study groups (twenty patients in each).
Tools of study Interpersonal problem solving procedure and Rosenberg self-esteem scale. The interpersonal problem-solving intervention: It consisted of five stages on seven sessions, four times\a week for two weeks.
Results There was a statistical significant improvement in the study group regarding their interpersonal problem solving skills and self- esteem as compares to the control group.
Recommendation It is essential to apply this intervention with large sample and long duration, and also used in various mental health services and facilities as a rehabilitative intervention for patients with schizophrenia.

Keywords: interpersonal problem solving, schizophrenia, self-esteem


How to cite this article:
Abo-Elyzeed SM, Harfush SME. Effect of an interpersonal problem solving intervention on problem solving skills and self-esteem in patients with schizophrenia. Egypt Nurs J 2019;16:59-69

How to cite this URL:
Abo-Elyzeed SM, Harfush SME. Effect of an interpersonal problem solving intervention on problem solving skills and self-esteem in patients with schizophrenia. Egypt Nurs J [serial online] 2019 [cited 2020 Jul 4];16:59-69. Available from: http://www.enj.eg.net/text.asp?2019/16/2/59/272393




  Introduction Top


Schizophrenia is characterized by a broad range of heterogeneous cognitive impairments that vary in their magnitude. Abnormalities are particularly obvious in the following cognitive domains: attention, memory, and executive functions (Orellana and Slachevsky, 2013). Some authors confirmed that the deficits in any of these cognitive areas may lead to ineffective interpersonal problem-solving and limit social and work functioning among patients with schizophrenia (Veltro et al., 2011). Secondary to deficits in interpersonal problem-solving skills, they have difficulty in establishing close interpersonal relationship, failure in coping with daily problems, and further maladjustment in the community. Such patients do not seem to know how to deal with other people in everyday situations (Uoka et al., 2010). This is considered a major contributor to the social prognosis or quality of life among many people with this disease. However, a poor social problem-solving skill is thought to be associated with their clinical symptoms, their elevated levels of emotional distress, and vulnerability to relapse (Bjerke et al., 2014; Bhattacharya, 2015).

It is inevitable that interpersonal problems arise in daily living, which requires assessing the situation and making appropriate responses, and it is clear that maladjusted behavior is more likely to occur in individuals who are unable to cope adequately with these problems (Pu Irene and Lu, 1990). Therefore, training patients with schizophrenia interpersonal problem-solving skills will be an important aspect for successful functioning in everyday life. Interpersonal problem-solving has been defined as the cognitive affective behavioral process by which people identify, discover, or invent effective or adaptive coping responses for specific problematic situations. It also refers to the process of coping with stressful situations with effective skills, based on purposefulness, awareness, rationality, and paying effect (Erozkan, 2013; Arslan, 2016).

Interpersonal problem-solving is important for psychosocial adjustment because it influences adaptive functioning across a wide range of stressful situations. Successful interpersonal problem-solving requires the capacity to define an interpersonal problem, to generate possible solutions that lead to the desired goal. It is one area of functioning that is thought to impact coping, and moderating the deleterious effects of stressful life events (Erozkan, 2013). To understand the components of interpersonal problem-solving in terms of its relevant cognitive functions, the construct has been divided into three sets of skills: receiving or decoding (identification and articulation of the complex elements of a problem), processing or decision-making (generation of suitable responses to the identified problem), and sending or encoding (subsequent to performance of one of these responses in a socially appropriate manner) (Bellack, 2004).

A variety of social skills training programs have been developed to treat the impairment in social functioning. For patients with schizophrenia, teaching problem-solving skills is not a new vision of rehabilitative therapy. Siegel and Spivack (1976) developed problem-solving therapy for patients with chronic schizophrenia to acquire skills of dealing with social problems effectively. The common goal of this program was to enhance adjustment, not by direct modification of behaviors themselves, but by altering an individual’s ability to think through and solve everyday problems that come up when interacting with others. The patients were guided to develop the habit of generating multiple options, evaluating these options, and planning the step-by-step means to reach a stated goal (Wallis, 2001).

Moreover, Yadav (2015) stated that patients who received problem-solving training improved their self-esteem and feeling of competence. Self-esteem is a personal judgment of worthiness; it is expressed in the attitude the individual holds toward himself/herself. It indicates the extent to which the individual believes himself/herself to be capable, significant, successful, and worthy. It is strongly associated with personal satisfaction and effective functioning (Rosenberg, 1979). High self-esteem is associated with a global feeling of self-liking and self-worth, respect, and acceptance. The higher the self-esteem, the more motivated the patient is to engage in self-care behaviors and it eventually reduces symptoms and improves the patient’s mood (Davis et al., 2012). Conversely, low self-esteem is associated with unhappiness and is assumed to have detrimental effects such as increased vulnerability to the stressors which affects the patient’s willingness to participate in the treatment plans (Berna et al., 2011). Without the benefit of positive coping skills to negotiate the challenges of daily living, the ability to defend against a self-rejecting attitude is limited (Pu Irene and Lu, 1990).

Several studies have found that individuals with schizophrenia are deficient in their ability to generate solutions to social problems, to evaluate the effectiveness of solutions, and to implement solutions when compared with healthy individuals, which negatively affect their self-esteem (Bjerke et al., 2014; Huanga et al., 2014; Favrod, 2018). If patients with schizophrenia consistency learn interpersonal problem-solving skills from a systematic method and successfully apply them in their daily life, the beliefs about self-competence in handling interpersonal problems will develop. This means that one of the important roles of psychiatric nurses is to teach patients with schizophrenia interpersonal problem-solving competencies to use it in their everyday interactions, and cope with daily social problems; it consequently improves their self-esteem and successful adjustment in the community.


  Aim of the study Top


This study aimed to determine the effect of a designed interpersonal problem-solving intervention on problem-solving skills and self-esteem of patients with schizophrenia.

Research hypothesis

A designed interpersonal problem-solving intervention is expected to improve problem-solving skills and self-esteem among patients with schizophrenia.

Operational definition

A designed interpersonal problem-solving intervention: It is an interpersonal problem-solving training through presented pictures, short stories on audiotape, scenes on videotape that reflect the social problems between two or more actors, followed by group discussion, explanation, guidance by researchers, thinking and responding by patients, using positive feedback, reassurance, and encouraging interaction, and reflection within group to acquire interpersonal problem-solving skills.


  Subjects and method Top


Research design

A randomized, control trial was applied in this study.

Setting

The study was carried out in a Psychiatry, Neurology, and Neurosurgery Center that is affiliated to Tanta University, Egypt. The capacity of this center is 28 beds divided into one ward for men (18 beds) and one ward for women (10 beds). It works 24 h/7 days/a week.

subjects

The participants of this study were 40 patients with schizophrenia. They were selected by the convenience sampling method. They met the following inclusion criteria: diagnosed with schizophrenia according to DSM-5 criteria, duration of illness less than 10 years since the last admission, and willing to participate in this study. The exclusion criteria includes: current or past substance-use disorder; neurological illness, acute medical illness, or mental retardation; and patients in acute disturbed state. The sample size calculation was done using EPi-Info software computer program software statistical package created by WHO and Center for Disease Control and Prevention, Atlanta, Georgia, USA, version 2002, based on the following criteria: 95% confidence limit, 80% power of the study, ratio between treatment and control group of 1 : 1, and expected level of self-esteem of 30% before intervention that will be improved to 70% after intervention. On the basis of the above-mentioned criteria the sample size will be 40 patients. The selected studied patients were divided randomly into control and study groups, each of them consisted of 20 patients.

Measures

Tool 1: Interpersonal problem-solving procedure (IPSP).

It was created by researchers after extensive review of the literature and guided by the mean-end problem-solving procedure, that is developed by Spivack et al. (1985) and assessment of interpersonal problem-solving skills, that is developed by Donahoe et al. (1990). This tool consisted of eight short stories of interpersonal interaction presented in a video format. Six stories reflected a problematic interpersonal situation that people may face during interaction in their daily life and other two stories are problem free. These two stories were used to minimize response bias.

The eight scenarios’ stories were written by the researchers and represented by the nursing students of Tanta University. The scoring system of IPSP was developed by assistance of a statistical expert. It was administered on the studied patients on an individual basis, they watched eight stories on laptop, and then were asked after each story according to the following subscales.

First subscale: identification of the problem, in which the studied patients were asked whether or not there was a problem? The responses yes or no was scored as either (1) if correct or (0) if incorrect. The other subscales depend on this question. The patients who were unable to give correct response should not move to the next questions or subscale.

Second subscale: description of the problem, the studied patients were asked to describe a problem, true description was scored (1), and false or unable to answer was scored (0). The patients who were unable to give correct response, he/she should not pass to the next questions or subscale.

Third subscale: steps of solving the problem, the studied patients were asked to think and find solutions or sequential steps that are necessary to solve an interpersonal problem that was watched in the videotape. The score was given according to the numbers of solutions reported by the patients in order to reach the story goal or solve the problem. The patients were given one point for each score.

Fourth subscale: obstacles of solving the problem.

These obstacles prevent the principal actor in the story to solve the problem or reach the goal. The score was given according to the numbers of obstacles reported by the patients. The patient was scored one for each true obstacle.

Fifth subscale: time factor.

The time was interpreted according to two contexts: (a) ability of the studied patients to recognize a time needed to reach a goal or for solving the problem. (b) Ability of the studied patient to select a suitable time to take purposeful action or each step of solving a problem. It was scored any indication of the passage of a specific amount of time before reaching the goal. The patients were given one point for each score.

Finally, the scores of all subscales were summed to each problem, and then to all problems. The higher scores that were gained by the studied patients means that increased ability to solve interpersonal problems. The mean score was calculated before and after implementation of the intervention.

Tool 2: Rosenberg self-esteem scale: this scale was developed by Rosenberg (1979). It is designed to represent a continuum of self-worth statements. It is consisted of 10 items, five positively worded and five negatively worded items. All items were coded on a four-point scale ranged from 0 (strongly disagree) to 3 (strongly agree). Items 2, 5, 6, 8, and 9 had to be reversed. Total scores range from 0 to 30, with higher scores indicating a higher global self-esteem. The Rosenberg self-esteem scale has a high internal consistency (the Cronbach alpha was 0.86).

Method

  1. An official permission to conduct the study was obtained from the Psychiatry, Neurology, and Neurosurgery Center to collect the study data.
  2. Ethical consideration:
    1. An informed consent was obtained from the studied patients after the explanation of the nature and purpose of the study.
    2. The studied patients were informed about the confidentiality and privacy regarding data collection and the intervention did not cause any harm or pain.
    3. The study patients had the right to withdraw from this study at any time.
  3. The IPSP was tested for content validity by a group of five experts in the field of psychiatric nursing. On the basis of this evaluation, some details were added in two stories’ scenarios.
  4. A pilot study was done on 10 patients with schizophrenia; these patients were excluded later from the actual study. Accordingly, some modification was done such as exclusion of few words and adding other words and details for more clarification.
  5. The study tools were tested for reliability and Cronbach’s alpha was used and found to be 0.794, and 0.927, respectively for tools 1 and 2 which represent highly reliable tools.


Data collection procedure

IPSP was administered on the studied patients individually by the researchers in four sessions: the first part of IPSP ‘four problems’ was applied in the first and second sessions. The second part ‘next four problems’ was administered in the third and fourth sessions as a pretest. In the same manner the IPSP was redemonstrated after the intervention implementation as a posttest. After applying the IPSP, the studied patients were divided randomly by a simple random method into two groups (20 patients for each). The patients in the study group were involved in the interpersonal problem-solving intervention, while patients in the control group had only the traditional treatment.

The intervention

It was developed by the researchers after an extensive review of the literature, and guided by the work of Siegel and Spivack (1976). The intervention consisted of five stages on seven sessions. It was applied on four small groups; each group was composed of five studied patients. Each studied group attended seven sessions/2 week/ 4 times a week. The stages of intervention were as follows:

Stage 1: recognition of interpersonal problems

This stage aimed to improve the ability of the studied patients to recognize interpersonal problems. This stage consisted of four exercises that were covered in two sessions (two exercises in each). The introductory session was included in this stage.

First session: introductory session

The researchers met the studied patients in a quiet room, its seats were arranged in a circular shape, they began by introducing themselves to patients, and asking each patient to introduce him/herself to the others. The researchers tried to establish an atmosphere of rapport, acceptance, and comfort. Then they gave a brief explanation about the intervention, its aims and importance, the intervention sessions, and the role of each researcher.

Second session

This session aimed to improve the studied patients’ attention and concentration, as a means of being able to recognize a problem once it occurs. This aim was met through the following exercises:

Exercise 1: This exercise consisted of slides about a changing environment. These slides were presented to each patient in the group for few minutes, then they were asked questions about these slides to test their attention to them. This exercise strengths their attention to what they see as a means of being better able to recognize problems when they occur.

Exercise 2: The group is shown a slide that contains a group of people. The next slide shows a new group of people with one familiar face from the earlier group. The patient’s task is to recognize the familiar face. Everyone in the group is asked individually which person was in both slides. This exercise strengths their attention to other people as another means of training the ability to recognize problems.

Third session

Through this session the researcher aimed to improve the abilities of the studied patients to recognize interpersonal problems concerning other’s feelings. This training was done through third and fourth exercises.

Exercise 3: ‘recognizing facial expression,’ in this the patients are shown pictures of people experiencing different emotions; then they were asked to recognize and describe these emotions. Through discussion, the participants were asked to explain why those people could experience these emotions.

Exercise 4: ‘finding problem’ consisted of two drawn pictures about problems in a real-life situation. The patient’s task was to discover what the problem in each picture is? For example, in one picture the problem is that there is only one piece of cake left between four people.

Stage 2: definition of interpersonal problem in clear statements

This stage aimed to improve the ability of the studied patients to define the social problem clearly. This aim was reached through teaching them how to seek and collect enough information about the problem until it becomes clearer. It consisted of two exercises that were applied in two sessions.

Fourth session

It involves two exercises.

Exercise 5: The researcher presented a problem to the patients and they began to ask many questions as a way to seek information about the problem. For example, finding a job and being late for an appointment. The group are not restricted to a limited number of questions. The task is intended to teach the patients how to gather information as one aspect of the ability to define problems.

Exercise 6: This exercise intended to train the studied patients on how to seek information from people who are considered a part of a problem. The group listens to three dialogs that were recorded on a mobile phone which illustrates various ways that people can find out what other people are thinking and feeling. The duration of each is ∼5 min. Through a group discussion, the researcher tried to teach the patients that there are two methods to seek information: direct and indirect. For example, a man’s car has broken down and he indirectly asks a friend, for a lift into town.

Stage 3: alternative ways of solving interpersonal problems

The aim of this stage was to train the studied patients to find out and create more ways to solve the interpersonal problem. These aims were met through the fifth session.

Fifth session

It was consisted of two exercises.

Exercise 7: The group tries to find alternative solutions to at least one interpersonal problem. They look at a drawing of an interpersonal problem and then at a number of drawings containing different solutions (two or more drawings to a solution) to the problem and the patient’s task was to put the drawings of each solution in the proper logical order.

Exercise 8: This exercise is intended to give the patient’s practice in thinking of rather than recognizing (as in exercise 7) alternative solutions to problems. The researcher asked them to think and write as many solutions to given interpersonal problems.

Stage 4: selection of the best solution to interpersonal problems from the alternatives

This stage aimed to teach the studied patients how to evaluate the effective solution of the problem and make a suitable decision. This aim was met by the sixth session.

Sixth session

The researcher began with an explanation about the type of problem solving: impulsive way (ineffective) and reflective way (affective) and differentiated between them. Following this explanation, the researcher trained the patients on Exercises 9 and 10.

Exercise 9: Two problems were presented on a videotape; one of them was an impulsive way of solving the problem and the other was a reflective way. Within group discussion the studied patients evaluate these ways and their consequences and were encouraged to discover the advantages and disadvantages of each way.

Exercise 10: The group is shown three sets of slides of people in situations where they must make a decision between two choices and list the advantages and disadvantages of each. Then each patient is asked to say which choice he/she would make. This is to give the patients practice in considering the advantages and disadvantages of alternative solutions to problems as an aid to becoming a better problem-solver.

Stage 5: role play about all stages of interpersonal problem-solving

This stage involved the application of all stages of interpersonal problem-solving that were demonstrated in previous sessions of the intervention. This was done through exercise 11.

Exercise 11: It presented an interpersonal problem on videotape and the studied patients; task was to discover the problem, recognize, and describe how people feel in this problem, ask questions to get information about this problem, create numerous solutions based on these information, consider advantages and disadvantages for each solution, and choose the best one, and finally applying this solution step by step through role play within the group.

The researcher used the following learning strategies such as group discussion, providing corrective feedback, positive reinforcement, lectures, brainstorming and learning materials such as: CDs, laptops, audiotapes, slides, colors, power point, notebook, paper, and pens.

Evaluation of the intervention

IPSP and self-esteem scale were readministrated on the study and control groups after implementation of the intervention as a posttest in the same manner that was applied before.

Statistical analysis

The collected data were organized, tabulated, and statistically analyzed using Statistical Package for Social Studies, version 19 created by IBM (Illinois, Chicago, USA). For numerical values the range, mean, and SDs were calculated. Differences of mean values between the two studied groups in relation to the total score of different stories were done using the Mann–Whitney test as the normal distribution was not guaranteed. Differences of mean value before and after intervention within each studied groups were done using Wilcoxon singed-rank test. For categorical variables, the number and percentage were calculated and differences between subcategories were tested by χ2 and Monte Carlo exact tests. Differences in the frequency distribution of subcategories between groups and within groups in relation to intervention were tested using the Mann–Whitney test and Wilcoxon’s singed-rank test, respectively. The correlation between two variables was calculated using Spearman’s correlation coefficient. The level of significance was adopted at P value less than 0.05.


  Results Top


[Table 1] represents the distribution of the studied patients with schizophrenia according to their sociodemographic and clinical data. It was noted that 65% of the studied patients in both study and control groups were men and 35% were women. The mean age of the study group was 33.20±6.40 and the control group was 34.35±6.27 years. Regarding their residence, nearly two-thirds (65%) of the study group came from urban area and 35% from rural, while 55% of the control group was staying in urban and 45% in rural area. In addition, 60% of the study group and 65% of the control group were single, and those who were married were 20 and 25% among the study and the control group, respectively, and just only 15 and 10% of the patients were divorced or widowed in both groups. Furthermore, the patients in both groups had various levels of education and jobs. Regarding clinical data, the duration of illness among patients in both groups were the same, and also somewhat similar in their number of hospital admission. The table also noted that 70 and 65% of the study and control groups received typical and atypical antipsychotic drugs, respectively, and the remaining received typical drugs in both groups. However, the Electro-convulsive Therapy (ECT) therapy was applied on 70% of the study group and 55% of the control group. There was no statistically significant difference between the study and the control group regarding all sociodemographic and clinical data.
Table 1 Distribution of the studied patients with schizophrenia according to their sociodemographic and clinical data

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[Table 2] explores the mean score of interpersonal problem-solving in both study and control groups before and after intervention. Regarding the subscales and total score of the problem-solving, there were highly statistically significant differences between the study and the control group after the intervention; the mean score in the study group was higher than the control group. For the study group, there is a highly statistically significant difference in favor in all subscales of problem-solving and total mean score at preintervention and postintervention. As for the control group, there is a mild statistically significant difference between preintervention and postintervention in problem identification and the total mean score of problem-solving.
Table 2 Mean score of interpersonal problem-solving skills among the study and control group before and after intervention

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[Table 3] concerns the comparison between the study and control groups regarding their self-esteem. There is a statistically significant difference between the study and control groups in patients’ self-esteem at postintervention (P=0.001). The mean score of patients’ self-esteem in the study group was higher than those in the control group (21.35±2.85 and 12.55±4.39, respectively). Moreover, in the study group there is a statistically significant difference between preintervention and postintervention of patients’ self-esteem (P=0.001), whereby the mean score after the intervention is higher than before (21.35±2.85 and 12.10±4.73, respectively). Concerning the control group, there is no statistically significant differences in the patient’s self-esteem at preintervention and postintervention (P=0.420).
Table 3 Mean score of self-esteem among the study and control groups before and after intervention

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[Table 4] shows the correlation between self-esteem and interpersonal problem-solving skills among patients with schizophrenia in the study group before and after intervention. From this table, it appears that there is a statistically significant positive correlation between self-esteem and subscales (problem identification, description, steps, obstacles, and time subscale) and the total score of interpersonal problem-solving (P=0.011, 0.001, 0.001, 0.001, 0.022, and 0.001). This means that the patients’ self-esteem increased with improving their abilities to solve interpersonal problems.
Table 4 Correlation between self-esteem and interpersonal problem-solving skills among schizophrenic patients in the study group before and after the program

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  Discussion Top


Impaired social functioning is a diagnostic feature of schizophrenia, and is present early in the course of illness. Studies have found that individuals with schizophrenia are deficient in their ability to generate solutions to social problems, to evaluate the effectiveness of solutions, and to implement solutions when compared with healthy individuals (Bjerke et al., 2014; Huanga et al., 2014; Favrod, 2018). During the past few years, many different cognitive rehabilitation programs have been developed and as a result many methods and approaches have emerged and supported that it is possible to introduce evidence-based psychosocial interventions for those who have poor social skills such as patients with schizophrenia and their functioning were improved even with a long history of mental disorders (Chien et al., 2013; Kluwe-Schiavon et al., 2013; Guhne et al., 2015; Lucksted et al., 2016).

The present study designed and implemented an interpersonal problem-solving intervention on hospitalized patients with schizophrenia and found that patients who participated in this intervention were improved on their abilities to solve social problems than before and also improved more than other patients who did not involve in this intervention and received only the traditional treatment. This was explained by a statistically significant increase of the scores of IPPS among the study group after the program more than before and more than the control group.

This result may be attributed to a combination of cognitive and behavioral therapy that focused on the sequential stages of training exercises ranging from simple to complex in the study intervention. It began with increasing the attention and concentration to the environment and other people as a means of paying attention to the problems when it occurred (exercises 1 and 2), recognize people’s emotion (exercise 3); this exercise helps the patients to learn that when they are involved in a relationship, they should understand others’ emotions through their facial expression. In agreement with Fiszdon and Johannesen (2010) who stated that there was a positive relationship between emotion identification and functional outcome domains involving social problem-solving and social skills. This relationship between accurately identifying emotions in faces and voices, and efficiently navigating the social environment indicates that these abilities could be useful treatment targets (Fiszdon and Johannesen, 2010). Moreover, the exercise that focuses on helping them find the problems by presenting pictures of problems concerning real-life situations helps the patients to acquire the skills more easily and more interesting for the patients.

As the patients progressed in the training stages, they transferred to more complex tasks. Seeking more information about the problem by asking many questions about it in an organized way help the patient to find more obstacles that might interfere with solving the problem. The finding of the present study shows statistically significant improvement in the obstacle subscale in the study group. This indicated that they learned to find out a solution and then evaluating the pros and cons for each solution selects the best one. By the end of the program, the patients reached the creativity, with their task to create a more alternative solution to solve interpersonal problems and take the best decision. All of these stages were implemented within a group, through group interaction. This made overload to researchers, they expended more effort to simplify the information, and make sure that those patients understand, and attempts endure trials and errors to reach the aim and resolve the conflict that aroused from those patients during their interaction together.

Holmes et al. (1984) were the first to assess the problem-solving skills of chronic aftercare psychiatric patients and demonstrated interpersonal problem-solving training with those patients, and the follow-up training was maintained for a period of 1–4 months. They concluded that the patients internalized the problem, solving component skills; they could successfully confront problems. In this context, Hansen et al. (1985) demonstrated the effectiveness of group interpersonal problems solving training with psychiatric patients; they concluded that such training improved patients’ ability to generate more effective verbal solution to everyday problems.

In addition, Reeder et al. (2017) found in their study that cognitive rehabilitation leads to improvements in social functioning of patients with schizophrenia regardless of baseline cognitive association. Furthermore, Rodewaled et al. (2010) assessed whether a problem-solving training is more effective in improving functional capacity including social problem-solving in 98 patients with schizophrenia than the traditional training program and reported that improvement of their functional capacity takes place when cognitive remediation is combined with other rehabilitation methods.

In the same line, Kluwe-Schiavon et al. (2013) presented a systematic review of 30 articles on executive functions rehabilitative intervention among patients with schizophrenia. These reviewed articles have pointed out that cognitive intervention could improve cognitive domains and social adjustment either by using computerized or paper and pencil programs. Additionally, cognitive training rehabilitation combined with a social problem-solving session were particularly effective. Recently, Roberts et al. (2014) designed social cognition and interaction training for outpatients with schizophrenia; their results suggested that training is feasible and well tolerated by participants, and conferred benefits in social problem-solving, negative symptoms, and possibly hostile attribution bias.

In the same direction, the study by Pu Irene and Lu (1990) used the observations of Siegel and Spivack (1976) on chronic schizophrenia to acquire problem-solving skills. They used 12 activities. They found that the patients who participated in this therapy had significant improvement in their abilities to solve interpersonal problems at least on a paper and pencil. It is important to highlight that this present study was guided by Siegel and Spivack’s therapy during developing its training program.

In this current study, the control group had significant increase in the ability to identify the problems and in the total score of IPPS but it was mild improvement compared with those in the study group. It is important to mention that the patients of the control group did not participate in any psychosocial training and received only the prescribed antipsychotic medication and/or electroconvulsive therapy.

Antipsychotic medication has not stopped the revolving door pattern of discharge and readmission in psychiatric facilities, and appears to retard, but not prevent relapse, even under the most favorable conditions drugs cannot teach life and coping skills for community adjustment (Chien et al., 2013). This means that psychosocial rehabilitation combined with neuroleptic drugs therapy may improve functional outcomes of schizophrenia. This is supported by consistent evidence that pointed out that the executive function of schizophrenia may be enhanced through a cognitive intervention program and it is an essential ingredient for those vulnerable populations (Magliano et al., 2016).

It is worth mentioning that the present study proved the impact of interpersonal problem-solving training on the self-esteem of the participants. The patients in the study group who attended this training had significantly higher self-esteem than before, and also than the patients in the control group. Furthermore, the self-esteem of those patients increased significantly with the increase of their abilities in each subscale and total sore of the IPSP. This finding is explained by numerous factors: first, the interpersonal problem-solving training had various activities, exercises, and plenty of materials (such as videos, colorful pictures, paper and pencil, etc.) and role plays. All of these could grasp the patient’s attention and increase his or her interest. Second, the patients who participated in the activities and exercises were motivated and encouraged to continue in the training. Third, the patient’s feeling of achievement that results from their ability to solve the problems can increase their self-esteem. Fourth, the feedback that was received from the researchers or/and participants made them to accepted themselves as worthy.

Supporting this explanation, a study conducted by Weiss (1999) proposed that repeated experiences of feeling competent about oneself might lead to general improvement in self-esteem over a period of time. This goes in line with Hesse et al. (2015) who stated that self-esteem in schizophrenia was found to be linked to depression and solving daily problems. In contrast, a study conducted by Pu Irene and Lu (1990) found that the self-esteem of patients with schizophrenia was not affected by the problem-solving therapy and explained it as a result of limited duration of intervention, the test–retest interval, and the small sample size. They suggested that the duration of the problem-solving therapy was not long enough to apply the skills to the external environment successfully and to form a feedback loop for increasing the self-esteem.

It is important to mention that the duration of the intervention in our study was short. Nevertheless, the intervention had a positive effect on the self-esteem, and their abilities to solve interpersonal problems. We expected that if this intervention is in long duration to follow up the patients in the community, it will have a higher positive effect on those patients’ competence.


  Conclusion Top


On the basis of the results of the present study, it can be concluded that interpersonal problem-solving intervention had a significant effect on improving the patient’s problem-solving skills and consequently enhanced their self-esteem.

Recommendations

On the basis of the results of the present study, the following recommendations were suggested:
  1. Interpersonal problem-solving training is an essential rehabilitative intervention for patients with schizophrenia. It is important to apply in broad settings of mental health services and facilities in the community.
  2. The intervention in the present study is needed to be applied in a large sample of patients and in longer duration to follow up their abilities to be integrated in the social life and cope effectively with its problems.
  3. Mental health professionals should use IPSP to assess the patients’ abilities to solve interpersonal problems, and they can modify it according to the patients’ culture.
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Acknowledgement

The authors acknowledge the nursing students in our faculty who represents the tool 1 ‘IPSP’ and all patients who participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Aim of the study
Subjects and method
Results
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