Effect of Social Competence Program on Self-esteem and Assertiveness among Schizophrenic Patients

Abd-Elmonem, Rasha Mamdouh; Abd-Elfatah, Sorayia Ramadan; Mohammed, Amany Anter

doi:10.21608/msnj.2019.187788

Effect of Social Competence Program on Self-esteem and Assertiveness among Schizophrenic Patients

Document Type : Original articles

Authors

¹ Assistant lecturer of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University

² Professor of Psychiatric Mental Health Nursing, Faculty of Nursing, Ain shams University

³ Lecturer of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University

10.21608/msnj.2019.187788

Abstract

Background: Patient with schizophrenia usually has lack of social skills and has an inability to communicate effectively with people, so that social competence program is needed for schizophrenic patients to improve their self-esteem and assertiveness skills .This study aimed to assess the effect of social competence program on self-esteem and assertiveness among schizophrenic patients Quasi experimental research design was utilized in this study .The study sample included 100 patients ,The study included four tools (I) structured Interview questionnaire to assess sociodemographic and clinical characteristics, tool (II) Rosenberg Self – Esteem Scale to assess level of self-esteem tool (III) Rathus Assertiveness Schedule to assess level of assertive behavior and tool (IV) Brief psychiatric rating scale to assess psychiatric symptoms. The result demonstrated that there were an improvement in total mean scores of self-esteem, assertiveness and psychiatric symptoms in post implementation as compared to its pre program implementation and follow up program implementation. Also the study showed that there, was statistically significant negative correlation between self-esteem and assertiveness among Schizophrenic Patients. It was concluded that there was highly statistically significant different in self-esteem, assertiveness and psychiatric symptoms after implementation of the program and in follow up assessment. The study recommended that collaboration between all health team members to develop specific goals for behavior modification, improving assertiveness and increasing patient's socialization.

Highlights

Rasha Mamdouh Abd-Elmonem ¹Sorayia Ramadan Abd-Elfatah ², Amany Anter Mohammed³

1. Assistant lecturer of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University

2. Professor of Psychiatric Mental Health Nursing, Faculty of Nursing, Ain shams University

3. Lecturer of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University

Keywords

Full Text

Introduction

Schizophrenia is a mental disorder characterized by abnormal behavior, strange speech, and a decreased ability to understand reality [1]. etiology of schizophrenia is not known, but it is thought to involve interactions between genetic and environmental factors, including developmental problems that occur during gestation [2].

Deficits in assertiveness skills are important components of social dysfunction in schizophrenia. Studies revealed that, patients with schizophrenia had numerous functional impairments across a wide range of assertiveness skills. For instance, behavioral analysis of schizophrenic patients‟ interactions revealed that they are lacking the ability to engage in effective social interactions, make request, express their opinions, refuse others‟ unreasonable demands, confirm and express their feelings, understand interpersonal boundaries and respond assertively to different situations[3].

Schizophrenic patients show unstable levels of self-esteem and are more likely to exhibit poorer responses to treatment and have a poorer quality of life; Patients with Low-self-esteem suffer from feelings of being weak, helpless, hopeless, frightened, fragile, incompetent, worthless and inadequate. They suffer from negative thoughts and fail to recognize their potentials, they fear criticism and take compliments negatively and are afraid of taking up responsibilities, and afraid of constituting their own opinion..[4]

Social competence is a term used by researchers to refer to how well a person is doing in day-to-day social situations. On measures of social competence, patients with schizophrenia are fare poorly[5]. It is necessary to provide social skills training according to the state of illness of the patient with schizophrenia. This training encourages human interaction and is expected to improve the patient's skills for conversation and assertiveness Social skills training are basically behavioral techniques that mainly emphasize on activity of daily living, conversational skills, and

Assertiveness skills, developing interpersonal relationships, and vocational training.[6].

Significance of the Study:

Through clinical experience, the researcher noticed that, a great number of patients have negative self-esteem, problems in communication skills including assertiveness and exaggerated psychiatric symptoms, therefore this study attempts to test the effectiveness of social competence program on self-esteem, assertiveness and psychiatric symptoms .Based on the obtained information, social competence program will be specially tailored, implemented, and evaluated for the study target population. Nurses can assist patients to become more assertive, promoting their self-esteem and fostering a respect for their own rights and the rights of others. Thus, social competence program is designed to enable schizophrenic patients to compensate for or eliminate the environmental and interpersonal barriers as well as the functional deficits created by this illness.

Previous Researches have found that an important prerequisite of the development of good social competence is that the individual should have positive self-esteem, positive attitude towards their environment and efficient communication are also important factors of social competence[7].

Aim of the Study

The study aimed to Evaluate the effect of social competence program on self-esteem and assertiveness skills among schizophrenic patients.

Research Hypothesis

The formulated research hypothesis:

The main research hypothesis is schizophrenic patients who are subjected to the social competence program have an improvement in level of self-esteem, assertiveness and psychiatric symptoms

H1: Application of social competence program on self-esteem among schizophrenic patients will improve. Self-esteem.
H2: Application of social competence program on assertive behavior among schizophrenic patients will improve. Assertive behavior.
H3: Application of social competence program on psychiatric symptoms among schizophrenic patients will decrease.

Working definition:

Social competence in this study is limited to self-esteem and assertiveness.

Subjects and Method

Research Design:

Quasi experimental research design (one group pre- test, post - test and follow up design) was used to achieve the aim of the study.

Setting

This study was conducted at Minia psychiatric health and addiction treatment hospital. The hospital consists of inpatient (psychiatric department, addiction department) and outpatient clinic; the capacity of hospital is 53 beds.

Subjects:

A convenience sample of 100 male and female schizophrenic patients admitted to the psychiatric inpatient unit was included in the study according to statistical equation (22*360/100), also sample size ranged between 10% to 30 % from total population size (Roscoe, 1975) and total population size admitted to Minia psychiatric health and addiction treatment hospital was 600 patients at previous year. The total numbers of schizophrenic patients were 360 patients at the previous year.

Inclusion Criteria:

Patients between the ages of 18 and 55 years.
Schizophrenic patients with different types.
The patient should be on treatment for at least three to four weeks prior to inclusion in the study.

Exclusion Criteria:

Mental retardation.
Comorbid diagnosis of substance dependence.
Organic brain disease.

Tools of Data Collection:

Tools of data collection consisted of four tools

Tool (1): consists of

A- sociodemographic and clinical data

It was developed by the researcher to collect data about gender, the educational level, marital status, duration of illness, date of admission, history of hospitalization, number of hospitalization, and total duration of hospitalization.

Tool (II) includes:

Rosenberg Self – Esteem Scale (RSE).

The Rosenberg self-esteem scale adopted to measure self-esteem [8] and translated into Arabic version. It consists of 10 statements (statements are phrased positively and 5statements are phrased negatively). These statements are rated on a 4-pointscale, which are: (1) strongly agree, (2) Agree, (3) disagree, (4) strongly disagree. According to these answers, scoring ranges from 1 to 40, with 40 indicating the highest possible score. Scoring for negative answers was reversed, i.e., 4 for strongly agree and 1 for strongly disagree, and so on.

Scoring system of self-esteem scale:

Higher score is an indicator of low self-esteem; moderate score is an indicator of moderate self-esteem while low score is an indicator of high self-esteem.

High self-esteem < 50% 20 score = Indicator of high self esteem
Moderate self-esteem 50%- 75% 21-30 score = indictor of moderate self esteem
Low self-esteem > 75% > 30 score = Indictor of low self esteem

(III)Rathus Assertiveness Schedule

Rathus assertiveness schedule adopted from[9] and translated into Arabic version, it was developed for measuring assertive behavior. It consists of 30 items ranged between (3+) very much like me to (3- ) very much unlike me. It scores from (90+) to (90- ), and the schedule statements numbers (1, 2, 4, 5, 9, 11, 12, 14, 15, 16, 17, 19, 23, 24, 26, 30) are reversed statements.

Scoring system of Rathus Assertiveness Schedule:

Assertive behavior 60% or more
Non Assertive behavior is less than 60%

Tool (IV) Brief psychiatric rating scale (BPRS):

The Brief Psychiatric Rating Scale (BPRS) First published in 1962 as a 16-construct tool by[10] the developer's added two additional items, resulting in the 18-item scale used widely today to assess the effectiveness of treatment, it is a widely used instrument for assessing the positive, negative, and affective symptoms of individuals who have psychotic disorders, especially schizophrenia.
Responses were measured on a 7- point Likert Scale where the highest score indicates the highest level of symptoms intensity.
The 7 categories for scoring system are (1) not present ,(2) very mild;( 3) mild; (4) moderate; (5) moderately severe; (6) severe; (7) extremely severe.

Scoring

Mild Brief psychiatric symptoms rating scale < 50%
Moderate Brief psychiatric symptoms rating scale 50% -75%
Severe Brief psychiatric rating symptoms scale ≥ 75%

Validity and Reliability

The tools were tested for content validity by a 5 jury of experts in the field of the study (Psychiatric Nursing) and the necessary modifications were done. Reliability of the study tools was done through used of coefficient test .r =.0.87for self-esteem, r = 0.93 for assertiveness while r = 0.91for psychiatric symptoms.

Procedure

A review of the related literature which covering various aspects of the problem was done, using available books and journals, to get acquainted with the research problem and to implement the study.

An official letter was obtained from the dean of the Faculty of Nursing, Minia University, as well as the director of Minia hospital for psychiatric health and addiction treatment, asking for permission to collect data and carry out the program. Oral and written consent was obtained from the patients after explaining the nature and purpose of the study through direct personal communication to gain their acceptance and cooperation. After that, data collection started; the researcher went to the hospital for three days ̸ week from 3-5pm (Monday,Tuesday, Wednesday).Fifteen patients had withdrew from the study.

Pilot study

Pilot Study was conducted on 10% from the total number which equal 10 patients of study sample to test the study process and to evaluate the efficiency, clarity, of tools that was used in the study. It also helped in the estimation of the time needed to fill the form. The necessary modification was done according to the result of the pilot study. Subjects who participated in the pilot study excluded from the actual study

The effect of social competence program on self-esteem and assertiveness

The proposed program was conducted through the following phases:

1. Assessment Phase:

This phase aimed at assessing social competence among schizophrenic patients; each patient interviewed to collect the necessary data .Based on the assessment phase, the program and media was prepared by the investigator in the form of booklet, posters, and videos.

2. Planning (Preparatory phase):

The planning phase included the program strategy time, number of sessions, teaching methods, media that was used. In addition, the teaching place and the program facilities checked for appropriateness. Number of sessions was 8 sessions, three sessions every week; the duration of each session was ranged from 30-60 minutes. Teaching sessions of the program conducted at conference room of Minia psychiatric health and addiction treatment hospital.

Program teaching methods:

A variety of teaching methods were included modeling, role playing, feedback reinforcement; group discussion sharing experience of the patients were utilized in this program.

3. Implementation of the program.

Oral and written agreement for participation are obtained from patients. The program was conducted by the researcher The program implemented for ten subgroups, each subgroup contains ten patients, the researcher applied the program on available first ten patients in the hospital and after finishing the program on these subgroups, applied the program on the second admitted ten patients until finished the ten subgroups. The same program implemented for each subgroup of patients. In some instances, sessions were carried out on a daily basis instead of 3 sessions per week. This is due to patients‟ shortened length of hospitalization and very high rate of turnover. Throughout the training program, instructional techniques, such as; group discussion, modeling, role playing, getting participants‟ feedback, providing corrective feedback had been used. This was done in order to make the skills very real and simple, and encourage patients to participate during the sessions and master the skills efficiently. At the end of each session, the researcher made a summary of what has been going on session.

The program content will be as follows:

1) Session 1: Includes introduction about the program (purpose, session's time, session's content, and effect on patient condition).

2) Session 2: Consists of brief explanation about signs and symptoms of chronic schizophrenia, immediate influence of these signs and symptoms on patients' interaction with others, and how gradually patient becomes withdrawn.

3) Session 3: Explains to the patient strategy of assertive communication which include of how to say "No". The patient can't say" No" or don't know how to do so.

4) Session 4: Applys to the patient astrategy of how to make requests; many patients are quite passive when it comes to making requests. They might felt they didn't have the right to ask. Or they might fear of the consequences of the request. The result indicated that , the patients avoid asking for help even when it was perfectly reasonable to do so.

5) Session 5: Applys skills for how to respond and give criticism assertively; and give constructive criticism.

6) Session 6: Practices skills of effective listening.

7) Session 7: Performs strategies of how to handle and express anger assertively.

8) Session 8: Consists of how to strengthen patient's self-esteem and improve Self-acceptance.

4. Evaluation of the program:

Evaluation was done to measure the progress of the patient's social competence. The pre-assessment tools were repeated again after 3 months of the program to measure the progress of the patient social competence .evaluation of the patient self-esteem, assertiveness and the psychiatric symptoms were done through the results of the pretest and posttest assessments of the experimental groups. Evaluation of test was done one time.

Ethical Consideration

A written initial approval was obtained from the Research Ethical Committee of the Faculty of Nursing, Minia University, there was no risk for study subjects during application of this research, the study followed common ethical participation in clinical research, privacy was provided during data collection. Anonymity and confidentiality was assured through coding the data; and a patient has the right to withdrawal to participate in the study without any rationale.

Statistical Analysis

Collected data were tabulated and needed statistical analyses was done utilizing the computer data processing using SPSS version (20). Acceptance level of significance was at P < 0.05.

Results

This study was conducted on institutionalized patients who have schizophrenia to determine the effect of social competence training program on self-esteem and assertiveness.

Table (1): Frequency distribution of socio-demographic data (N=85).

Socio-Demographic data	No.	%
Gender
Male	58	68.2
Female	27	31.8
Marital Status
Single	45	52.9
Married	36	42.4
Divorced	4	4.7
Education level
Illiterate	19	22.4
Primary (reads and writes)	4	4.7
Elementary or Secondary	50	58.8
University	12	14.1

Table (1): demonstrated that, more than half of studied were Males (68.2%), and about (52.9%) were single about (58.8%), had Elementary or Secondary school level .

Table (2): Frequency distribution of Clinical Characteristics (No= 85)

Medical characteristics	No	%
Duration of disease Less than one year From year to less than two years From two years to less than three years More than 3 years	5 8 9 63	5.9 9.4 10.6 74.1
How many Admission (N=59)
Once	22	25.9
Twice	24	28.2
Three times	9	10.6
More than three times	5	5.9
Staying Time (N=59)
Less than 1 month	8	9.4
From 1 month to 2 months	48	56.5
Three months	3	3.5
More than three months	1	1.2

Table (2) :demonstrated that more than three quarter of patients were admitted more than 3 years (74.1%), about most of patients had at least one institutionalized admission (25.9%), about half of the patients had Staying From 1 month to 2 months (56.5%),

Table (3): Comparison between pre, post and follow-up among studied sample in relation to their self-esteem (N=85).

Total self-esteem level	Pre		Post		Follow-Up		Chi-square test
Total self-esteem level	No.	%	No.	%	No.	%	x2	p-value
High self-esteem ≤20%	4	4.7%	34	40.0%	2	2.4%	58.957	<0.001**
Moderate self-esteem >20-50%	80	94.1%	51	60.0%	83	97.6%
Low self-esteem >50%	1	1.2%	0	0.0%	0	0.0%
Total	85	100.0	85	100.0	85	100.0

**p-value <0.001 HS

This table showed there were highly statistically significant differences between pre, post and follow-up in relation to self-esteem among schizophrenic patients with p-value (<0.001 HS).

Table (4): Comparison between pre, post and follow-up among studied sample in relation assertiveness behavior (N=85).

Total Rathus assertiveness Schedule	Pre		Post		Follow-Up		Chi-square test
Total Rathus assertiveness Schedule	No.	%	No.	%	No.	%	x2	p-value
Non assertive behavior <60%	47	55.3%	8	9.4%	14	16.5%	52.574	<0.001**
Assertive behavior >60%	38	44.7%	77	90.6%	71	83.5%
Total	85	100.0	85	100.0	85	100.0

**p-value <0.001 HS

This table indicated that there were highly statistically significant differences between pre, post and follow-up in relation to assertive behavior among schizophrenic patients with p-vale (<0.001 HS).

Table (5): Comparison between pre, post and follow-up in relation to their total Brief psychiatric rating scale (N=85).

Total Brief psychiatric rating scale	Pre		Post		Follow-Up		Chi-square test
Total Brief psychiatric rating scale	No.	%	No.	%	No.	%	x2	p-value
Mild symptoms <50%	22	25.9%	60	70.6%	82	96.5%	95.070	<0.001**
Moderate symptoms 50-80%	55	64.7%	23	27.1%	3	3.5%
Severe symptoms >80%	8	9.4%	2	2.4%	0	0.0%
Total	85	100.0	85	100.0	85	100.0

**p-value <0.001 HS

This table showed that, there were highly statistically significant differences between pre, post and follow-up in relation to psychotic symptoms with p-vale (<0.001 HS).

Table (6 ): Relation between self-esteem of studied sample and their socio demographic characteristics (N= 85).

Socio-Demographic data	Pre program		Post program		Follow Up
Socio-Demographic data	Mean	±SD	Mean	±SD	Mean	±SD
Gender
Male	23.90	2.80	21.48	1.89	23.03	1.71
Female	24.63	3.01	21.56	1.72	23.07	2.11
T	1.202		0.029		0.009
p-value	0.276		0.866		0.927
Age (years)
≤30 years	24.13	2.90	21.29	1.81	23.13	1.92
>30-40 years	24.09	2.83	21.59	1.83	22.88	1.62
>40 years	24.20	3.10	21.87	1.92	23.20	2.11
F	0.007		0.588		0.230
p-value	0.993		0.558		0.795
Marital Status
Single	23.94	2.87	21.49	1.90	22.86	1.73
Married	24.32	2.79	21.67	1.80	23.19	1.87
Divorced	24.80	3.90	20.25	0.50	24.00	2.55
F	0.309		1.085		1.040
p-value	0.735		0.343		0.358

This table demonstated the relation between schizophrenic patient's sociodemographoc data and pre, post and follow total self-esteem It was found that ,there was no statistically significant relation among patients with schizophrenia between levels of self-esteem and socio demographic data.

Table (7) Relation between self-esteem of studied sample and their clinical characteristics (N= 85).

History	Pre program		Post program		Follow Up
History	Mean	±SD	Mean	±SD	Mean	±SD
Duration of disease
Less than one year	22.83	2.48	22.00	2.83	24.00	1.67
From year to less than two years	23.50	2.98	22.25	1.98	22.75	1.91
From two years to less than three years	23.88	3.04	21.33	1.50	23.25	2.43
More than 3 years	24.37	2.89	21.40	1.78	22.97	1.77
F	0.689		0.656		0.675
p-value	0.561		0.582		0.570
How many Admission
No	22.88	2.39	21.44	1.78	23.00	1.55
Once	24.44	3.04	21.41	1.92	23.24	2.13
Twice	25.00	2.98	21.96	2.03	22.71	1.31
Three times	25.29	2.75	20.78	1.48	23.29	3.09
More than three times	23.83	2.71	21.40	1.14	23.33	1.86
F	2.192		0.742		0.303
p-value	0.047*		0.566		0.875
Staying Time
No	22.88	2.39	21.44	1.78	23.00	1.55
Less than 1 month	24.44	1.51	22.38	2.00	23.33	2.29
From 1 month to 2 months	24.84	3.03	21.44	1.83	23.04	1.93
Three months	19.00	0.00	21.33	2.31	22.00	0.00
F	4.129		2.204		0.183
p-value	0.009*		0.641		0.908

It indicated that, there was statistically significant differences between levels of self-esteem scale and clinical characteristics.

Table (8) Relation between Assertiveness of studied sample and their socio demographic characteristics (N= 85).

Socio-Demographic data	Pre program		Post program		Follow Up
Socio-Demographic data	Mean	±SD	Mean	±SD	Mean	±SD
Gender
Male	-3.03	22.90	26.05	18.66	24.09	18.11
Female	-9.52	26.12	32.00	20.20	19.81	22.38
T	1.350		1.777		0.879
p-value	0.249		0.186		0.351
Age (years)
≤30 years	-6.79	30.10	28.18	18.61	20.95	19.52
>30-40 years	-1.38	15.38	25.44	20.07	25.25	19.40
>40 years	-8.73	22.02	32.67	19.40	21.87	20.64
F	0.646		0.721		0.433
p-value	0.527		0.489		0.650
Marital Status
Single	-6.41	25.41	27.11	19.00	23.73	20.67
Married	-4.42	19.23	28.03	20.35	21.13	18.25
Divorced	3.60	38.14	36.50	11.56	22.80	18.93
F	0.408		0.432		0.166
p-value	0.666		0.651		0.848

This table showed that there was no statistically significant differences between levels of assertiveness and sociodemographic characteristics .

Table (9) Relation between Assertiveness of studied sample and their clinical characteristics (N= 85).

History	Pre program		Post program		Follow Up
History	Mean	±SD	Mean	±SD	Mean	±SD
Duration of disease
Less than one year	3.17	12.89	31.00	33.49	17.00	23.33
From year to less than two years	6.25	13.37	33.75	18.86	36.25	17.45
From two years to less than three years	11.88	15.29	28.33	19.75	20.75	15.00
More than 3 years	-9.48	25.31	26.90	18.24	21.81	19.63
F	3.078		0.339		1.553
p-value	0.032		0.797		0.207
Does entry before
No	3.35	18.38	28.28	18.68	24.12	19.31
Yes	-8.81	25.35	27.80	19.63	22.12	19.77
T	4.844		0.011		0.187
p-value	0.031		0.917		0.667
How many Admission
No	3.35	18.38	28.28	18.68	24.12	19.31
Once	-0.76	21.59	27.68	25.02	24.76	19.81
Twice	-19.00	26.85	27.04	15.88	20.71	17.96
Three times	-8.29	19.86	34.44	14.43	27.86	24.36
More than three times	-7.33	33.13	20.00	18.75	9.33	19.03
F	3.094		0.474		0.981
p-value	0.020		0.755		0.423

This table declared that there were statistically significant differences between assertiveness levels and clinical characteristics among schizophrenic patients.

Table (10) Relation between psychiatric symptoms of studied sample and their socio demographic characteristics (N= 85).

Socio-Demographic data	Pre program		Post program		Follow Up
Socio-Demographic data	Mean	±SD	Mean	±SD	Mean	±SD
Gender
Male	59.55	13.25	44.12	13.68	29.02	6.86
Female	57.93	13.57	42.30	15.44	28.67	9.75
T	0.273		0.302		0.036
p-value	0.602		0.584		0.849
Age (years)
≤30 years	60.18	13.06	43.16	14.23	31.47	8.79
>30-40 years	57.00	13.77	43.72	16.10	26.38	6.69
>40 years	60.47	13.19	44.13	9.96	27.80	5.54
F	0.599		0.029		4.152
p-value	0.552		0.972		0.019*
Marital Status
Single	59.18	13.57	43.33	14.87	28.88	7.22
Married	57.65	12.17	44.31	14.02	29.06	9.16
Divorced	66.20	17.58	39.00	8.37	28.20	5.67
F	0.897		0.257		0.026
p-value	0.412		0.774		0.974

This table demonstrated that there were no statistically significant differences between levels of psychotic symptoms and sociodemographic data, while there was statistically differences between psychotic symptoms and patient's age

Table (11) Relation between psychiatric symptoms of studied sample and their clinical characterstics (N= 85).

History	Pre program		Post program		Follow Up
History	Mean	±SD	Mean	±SD	Mean	±SD
Duration of disease
Less than one year	48.67	14.22	39.00	12.47	28.17	4.92
From year to less than two years	52.25	11.84	38.00	8.49	29.00	9.72
From two years to less than three years	55.50	8.07	42.44	8.35	25.38	4.47
More than 3 years	61.33	13.28	44.76	15.44	29.41	8.14
F	2.916		0.743		0.640
p-value	0.039*		0.529		0.592
Does entry before
No	59.92	11.37	44.52	13.57	28.73	5.46
Yes	58.64	14.13	43.13	14.54	28.98	8.72
T	0.166		0.167		0.019
p-value	0.685		0.684		0.892

It was observed that, there was statistically significant differences between levels of psychotic symptoms of schizophrenic patients and duration of disease .

Table (12): Correlation between post Rosenberg self-esteem scale, Rathus assertiveness and brief psychiatric rating scale among Schizophrenic Patients (No =85).

Post		Rosenberg Self Esteem Scale	Rathus Assertiveness Schedule	Brief psychiatric rating scale
Rosenberg Self Esteem Scale	R		-0.303	0.188
Rosenberg Self Esteem Scale	p-value		0.005*	0.086
Rathus Assertiveness Schedule	R	-0.303		-0.002
Rathus Assertiveness Schedule	p-value	0.005*		0.986
Brief psychiatric rating scale	R	0.188	-0.002
Brief psychiatric rating scale	p-value	0.086	0.986

*p-value <0.05 S; **p-value <0.001 HS

Spearman's rank correlation coefficient (rs)

Table 12 showed that, there was significant negative correlation between post Rosenberg self-esteem scale and rathus assertiveness schedule among Schizophrenic Patients.

Discussion

Research evidence recognizes low self-esteem to occur in several psychiatric disorders, particularly major depressive disorders, dysthymic disorder, anxiety disorders and schizophrenia[11] patient with schizophrenia usually lack social skills and have an inability to communicate effectively with people ,confirm and express their feelings ,and understand interpersonal boundaries, they may solve their problems in an unsuitable manner or may have few solution[12] . The aim of this study was evaluate the effect of social competence program on self-esteem and assertiveness.

To fulfill the objectives of this study, findings are presented in main parts

Which include the following:

Part (I): Sociodemographic and clinical characteristics of the studied

Patients

As regard to the gender of the participants, the present study revealed that, about more than half of the studied participants were males .This might be due to culture which represented as hinder to female institution .The result also was consistent with[13] about “Gender Differences within the Psychosis Spectrum” who reported that, the prevalence of specific diagnoses differed between men and women men were approximately 1.4 times more likely to have a diagnosis of schizophrenia than were women.

As regarding marital status, the present study revealed that, the majority of the studied participants were single .This might be related to onset of the disease appear early in male than in female and also may be due to stigma of the disease .This result agreed with [14] who mentioned that The vast majority of the patients were unmarried. This result also congruent with[15] who found that 44.44% of cases were unmarried.

Concerning the education of the participants, the study demonstrated that more than half of the subjects had secondary school and small numbering of the participants had university education, this might be related to severity of the symptoms which affect on the level of education. This result agreed with[16] who showed that ,more than one third of the sample had preparatory or secondary education, while only 15.4% of patients had a university education.

As regard to occupation, the present study showed that, more than half of the participants were unemployed .This might be due to many causes which might include factors related to the illness, frequent hospitalization, might be the result of combination of public discrimination and patients‟ perceived stigma, as well as side effects of antipsychotic drugs .This result agreed with [15] who found that, about half of cases were unemployed

Regarding the clinical characteristics of the participants, more than three quarters of the participants their duration of the disease was more than three years .This might be due to the chronicity of the disorder. This was in agreement with the literature[17] who mentioned that, schizophrenia is associated with many costs to the health care system as it often presents early in life, has no cure, requires repeated interaction with the health care system, lifelong medications and frequent hospitalizations

The present study showed that, about nearly half of the participants were admitted to hospital between twice and three times .This might be related to the relapse of the disease so that, it increase the number of hospitalization. This finding was congruent with [18] who found that half of the participants had one hospitalization and 40.0%had 2–4 hospitalizations .

The result of the present study also showed that, more than three quarters of the participants had previous hospitalization and duration of staying was between one months to two months this might be related to policy of the hospital , this finding was inagreement with[14] who found that , The length of current hospitalization ranged from 1 to 64 days.

Part (II) Effect of the competence training program on self-esteem, assertiveness and brief psychiatric symptoms.

The result revealed that, there was highly statistically significant difference between participants regarding self-esteem before and after the implementation of the program .This might be related to the effectiveness of social competence program which helped the patient to be able to achieve different issues as the “ability to achieve legitimate, ability to share in discussion , ability to express emotion ,ability to express weakness and strengths of patient personality This finding was consistent with[19] who mentioned that Coping skills and social competence confer not only protection against stress-induced relapse but also resilience, interpersonal supports, social affiliation, and improved quality of life.

On the other hand, This result was not consistent with [20]who showed that, there was no statistically significant difference between the mean scores of the pretest (20.33+4.38) and for the post intervention regarding the effect of Assertive Training Program on Social Interaction Anxiety and Self - Esteem of Institutionalized Patients with Chronic Schizophrenia .

Regarding assertiveness skills after implementation of the program, this study revealed that assertiveness skills were developed after the implementation. This might be related to effect of social competence program which enhance assertiveness skills. This finding agreed with[21] who found that, individuals with chronic schizophrenia significantly improved in assertive behavior, decreased social anxiety, and increased self-reported satisfaction with interpersonal communication immediately following treatment and at the three month follow up.

As regard to brief psychiatric symptoms, there were highly statistically significant difference between pre ,post assessment after program implementation .This might be related to effectiveness of training program which has apositive effect on self-esteem and assertiveness skills so subsequently affect on decrease in brief psychiatric symptoms. This findings was consistent with[22] who indicating that assertiveness training can improve various clinical symptoms above and beyond assertive behavior. On the other hand[23]concluded that social skill training has no effect on psychopathology

Part (III): Differences and correlation between socio demographic and clinical characteristics

In relation to participant's self-esteem and their gender , the finding of the current study revealed that ,there were no statistically significant differences relation between participant self-esteem score pre ,post and follow social competence implementation .This finding was agreed with[24] who stated that, relationship between self-esteem and Socio-demographic characteristics of the studied sample of schizophrenic patients at ‟ pre and post program implementation showed that, there was no statistical significant differences between self-esteem mean score and gender of the studied sample pre or post program.

In relation to participant's self-esteem and their duration of disease, the finding of the current study revealed that, there were statistically significant differences between participants self-esteem score at pre, post and follow the social competence implementation. This finding may be related to institutionalization itself that cause major deterioration in a majority of skills that negatively affect patient's self-esteem. This finding was agreed with[25] Who found that, with chronicity of illness in addition to institutionalization, patients start to escape from reality , use more less effective coping methods and become more socially isolated due to anxiety about interactions or over hostile behavior.

In relation to participant's age and self-esteem, the finding of the study showed that, there were no statistically significant differences between participants self-esteem and their age at pre, post and follow social competence implementation .This result was consistent [20] who mentioned that there were no statistically significant differences among patients' age groups and social anxiety score and self-esteem .

The present study showed that, there were no statistically significant differences between participants, socio demographic data and assertive behavior and nonassertive behavior regarding social competence implementation .These results were supported by [14] who found that, no statistically significant differences between the study group all socio-demographic and almost all clinical factors .On the other hand, these findings were unsupported with[26] who found that, there were statistically significant differences between the study groups level of assertiveness and educational levels.

In relation to participants brief psychiatric symptoms and their age, the finding of the current study indicated that, there was highly statistically significant difference in psychiatric symptoms at the follow up of social competence implementation rather than before implementation of the program. This finding was in disagreement with [27] who documented that, there were no statistical significant differences between Egyptian patients' age and total negative symptoms, total positive symptoms, and total general psychopathology scores.

In relation to brief psychiatric symptoms and duration of the disease, the finding of the current study indicated that, there was statistically significant relation between psychiatric symptoms and duration of the disease .This finding was congruent with[27]who illustrated that Saudi patients' duration of illness was statistically significant related with total general psychopathology scores On the other hand, there were no statistical significant differences between Egyptian patients' socio-demographic and medical data and total negative symptoms, total positive symptoms, and total general psychopathology scores.

The present study reported that, there was a significant negative correlation between self-esteem and assertiveness skills of studied sample post program implementation .this result indicted that, patients who have assertiveness skills have high level of self-esteem .This result was consistent with[28] who Indicted that, results of studies focusing on disorder-specific symptoms, there is evidence that unassertiveness is associated with other trans diagnostic factors that are broadly that are broadly related to psychopathology, such as lowered self-esteem and self-concept .Finally, it can be concluded that, social competence training program can affect on reduction of symptoms of schizophrenia patients, improve self-esteem and assertive behavior .

Conclusion

Based on the study findings, which revealed there were highly statistically significant differences between pre and post intervention regarding self-esteem, assertiveness and psychiatric symptoms, so the findings of the present study indicated that, social competence program had apositive effect on self-esteem, assertiveness and psychiatric symptoms of the schizophrenic patients after receiving social competence program.

Recommendation

In light of the results of the current study, the following recommendations are suggested:

1) Social skills training program should be held for all psychotic patients in hospitals to improve their social competence and self-esteem.

2) Collaboration between all health team members to develop specific goals for behavior modifications, improving assertiveness and increasing patient's socialization

3) Further studies are required concerning social skills and assertiveness

References

1) National institute of mental health, schizophrenia. 2016. Available at: Www.nimh.nih.gov/health topics/schizophrenia/index.shtml.Retrived on February 2016.

2) Rodrigues-Amorim, D., et al., Schizophrenia: a review of potential biomarkers. Journal of psychiatric research, 2017. 93: p. 37-49.

3) Bellack, A.S., et al., Social skills training for schizophrenia: A step-by-step guide. 2013: Guilford Publications.

4) Ho, R., Wan,A.,et al., he psychophysiological effects of Tai-chi and exercise in residential schizophrenic patients :a3- arm randomized controlled trial .BMC,complementary and alternative Medicine,. 2014. 14:364.

5) Ballon, J.S., Kaur, T., Marks, I.I., & Cadenhead, K.S. , Socialfunctioning in young people at risk for schizophrenia. , , . Psychiatry Research, 2007. 151: p. 29–35.

6) Singh U, S.B.a.S., Assessment and Management of Socio-ccupational Functioning of Persons with Chronic Schizophrenia: Effect of Social Skills Training, Journal of Psychosocial Research. Journal of Psychosocial Research, 2018. Vol. 13, No. 1, : p.,189-198.

7) Scott J, C.F., Vieta E, A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders. Int J Neuropsychopharmacol., 2007. 10(1): . p. 123–129.

8) Rosenberg, M., Conceiving the self. New York :Basic Books., 1979.

9) Nevid, J.S., & Rathus, S. A., Multivariate and normative data pertaining to the RAS with the college population. Behavior Therapy,. 1978. 9, 675.

10) Overall, E., Gorham ,R.,, The Brief Psychiatric Rating Scale (BPRS): recent developments in ascertainment and scaling. Psychopharmacology Bulletin. 1988. 24: p. :97-99.

11) Lysaker, P.H., et al., Associations of multiple domains of self-esteem with four dimensions of stigma in schizophrenia. Schizophrenia Research, 2008. 98(1-3): p. 194-200.

12) kupper, z.R.F., Hoffmann,H&Wolfgang Tsschacher, Nonverbal Synchrony in Social Interactions of Patients with schizophrenia Indicates Socio-Communicative Deficits, . National library of medicine ,, 2015. 10(12).

13) Diaz, L., C., . Leroy,K,H., Lourdes Nieto,M., Arroyo,M,B., Cabello,H,R., Angel Herrera,M,E.,Chaves,M,C., Luis Aviٌa,C,A, Gender Differences within the Psychosis Spectrum. Neuropsychiatry (London) 2018. 8(4), : p. 1186–1195.

14) Mousa, A., S. Imam, and A. Sharaf, The effects of an assertiveness training on assertiveness skills and social interaction anxiety of individual with schizophrenia. Journal of American Science, 2011. 7(12): p. 454-466.

15) Madhura D Ashturkar1, J.V.D., SELECTED EPIDEMIOLOGICAL ASPECTS OF SCHIZOPHRENIA: A CROSS SECTIONAL STUDY AT TERTIARY CARE HOSPITAL IN MAHARASHTRA. National Journal of Community Medicine, 2013. Volume 4,Issue 1,Jan ,: p. Page 65.Available at www.njcmindia.org.

16) RS, E., M. Maximos, and A. Sharaf, The Relation between Coping Strategies and Social Support among Patients with Schizophrenia. Age (Years). 30(28): p. 18.7.

17) schizophrenia.( . National alliance on mental illness 2015).Retrieved January 2, 2016.

18) Koutra, K., et al., Impaired family functioning in psychosis and its relevance to relapse: a two-year follow-up study. Comprehensive psychiatry, 2015. 62: p. 1-12.

19) Salokangas, R.K., et al., Subjective life satisfaction and living situations of persons in Finland with long-term schizophrenia. Psychiatric Services, 2006. 57(3): p. 373-381.

20) Mohamed, S.M. and E.M. AbdElAziz, Effect of Assertive Training Program on Social Interaction Anxiety and Self-Esteem of Institutionalized Patients with Chronic Schizophrenia.

21) Lee, T.Y., et al., The effects of assertiveness training in patients with schizophrenia: a randomized, single‐blind, controlled study. Journal of advanced nursing, 2013. 69(11): p. 2549-2559.

22) Speed, B.C., B.L. Goldstein, and M.R. Goldfried, Assertiveness training: A forgotten evidence‐based treatment. Clinical Psychology: Science and Practice, 2018. 25(1): p. e12216.

23) Bustillo JR, L.J., Horan WP, Keith SJ, The psychosocial treatment of schizophrenia. American Journal of Psychiatry., 2001. 158: . : p. 163–175.

24) El Malky, M., I.,Attia,M,M.,Alam,F,h,, The effectiveness of social skill training on depressive symptoms ,self esteem and interpersonal difficulties among chizophrenic patients international journal of Nursing studies,). , 2016. 5(1: p. 43-50.

25) Ku, J., Han,K.,Lee,H,R.,Jang,H,J.,Kim,K,U.,&Park,S,H, VR- based conversation training program for patients with schizophrenia preliminary clinical trial .Cyber psychology &Behavior 2007. 10(4):: p. 567-574.

26) Barakat, M., Khodiar,A., Elmalky, M., &Elashry, N, The Effect of an Assertiveness Training Program on Schizophrenic Patients.Benha University. 2015.

27) Mohamed, N.H., et al., Relationship between Caregiver's Expressed Emotions and Patient's Symptoms Severity among Schizophrenic Patients: A Comparative Study.

28) Goldfried, M.R., On possible consequences of National Institute of Mental Health funding for psychotherapy research and training. Professional Psychology: Research and Practice, 2016. 47(1): p. 77.