RESEARCH ARTICLE Turkish Journal of Psychiatry 2024;35(2):102−115

https://doi.org/10.5080/u26773

The Effects of Art Therapy and Psychosocial Skills Training on

Symptoms and Social Functioning in Patients with Schizophrenia
and Their Relatives
2
Aslı Sarandöl1 , Rümeysa Ayşe Güllülü2 , İlknur Kiraz Avcı3 , Eralp Türk4 ,
Salih Saygın Eker5

ABSTRACT
Objective: The effects of antipsychotics on negative symptoms are limited. The most appropriate approach in the treatment of schizophrenia is
the integration of drug therapy with psychological and social interventions. The purpose of this study was to evaluate and compare the effects of art
therapy and psychosocial skills training (PSST) in the treatment of schizophrenia.
Methods: A total of 15 patients diagnosed with schizophrenia according to the criteria in DSM-5 and 12 patient relatives were included in the
study. The patients were randomly divided into 2 groups, 7 were included in the art therapy program and 8 were included in the PSST program for
schizophrenia. 90-minute sessions of art therapy and PSST were carried out once a week for 17 weeks. Participants with schizophrenia were evaluated
with the Positive and Negative Syndrome Scale (PANSS), Social Functioning Scale (SFS) and the Calgary Depression Scale for Schizophrenia and
the relatives were given Beck Depression Inventory, Beck Anxiety Inventory and Zarit Burden Interview.
Results: There was a significant decrease in the PANSS negative symptoms, PANSS general psychopathology, SFS pro-social activities and SFS
recreation scores in both groups, while the SFS social withdrawal scores decreased significantly only in the art therapy group. In the PANSS negative
symptoms subscale, passive social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation and stereotyped thinking
scores were significantly lower in the art therapy group. In the PSST group only the score for difficulty in abstract thinking declined significantly.
Conclusion: The findings of the present study suggest that art therapy and PSST have positive effects on the improvement of negative symptoms as
well as improvements in social and cognitive functionality in schizophrenia.
Keywords: Schizophrenia, Art Therapy, Psychotherapy Group, Psychosocial Skills Training, Social Functioning

INTRODUCTION of symptoms and improve functionality in schizophrenia

patients (Schooler 2006).
Schizophrenia is a life-long chronic disease manifested mainly
by positive, negative, cognitive and mood symptoms, heavy Addition of Psychosocial Skills Training (PSST) to drug
social and economic costs and significant deterioration in therapy in the treatment of schizophrenia is a structured,
quality of life and functionality. Although antipsychotics interactive and systematic training approach applied
are the first-line treatment in schizophrenia, their effects on individually or in groups. PSST is a program that allows
the residual type and negative symptoms are very limited. patients to become aware of their disease and condition,
Even patients responding well to drug therapy are at risk of facilitates coping with the disease, prevents exacerbations and
impaired social adaptation and functionality, and poor quality relapses of the disease, increases their insight into the disease,
of life. Integration of drug therapy with various psychosocial adherence to medication, social functionality, personal and
interventions in schizophrenia helps prevent the recurrence social life skills, and quality of life (Yıldız et al. 2005). The

Received: 08.07.2021, Accepted: 20.04.2022, Available Online Date: 19.02.2024

Prof., 2MD., Uludağ University Faculty of Medicine, Department of Mental Health and Diseases, Bursa; 3MD., Rize State Hospital, Department of Mental Health
1, 5

and Diseases, Rize; 4MD., Bursa Yüksek İhtisas Training and Research Hospital, Mental Health and Diseases, Bursa, Turkey.
e-mail: [email protected]

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PSST program for schizophrenia was designed by Yıldız that family functionality is impaired when the functionality
(2011) to improve the psychological and social skills of of schizophrenia patients is impaired, which affects the
patients based on the cognitive and behavioral treatment clinical course of the patient (Danacı et al. 2005, Friedmann
techniques in some modules of the Social Skills Training et al. 1997). Therefore, it is necessary to include the families
implemented by Liberman (1986, 1987, 1988). Studies with in the treatment plan.
PSST in schizophrenia patients and their relatives found that
there was a decrease in clinical symptoms and depressive Sarandöl et al. (2013) applied art therapy methods in
symptoms, and an increase in quality of life and social schizophrenia patients and their relatives in group works
functionality in the patient group (Yıldız et al. 2002, Üçok et in their study and achieved significant improvements in
al. 2002, Deveci et al. 2008). the symptoms of the disease, as well as personal and social
skills. The researchers focused on whether these changes
Art therapy is a psychotherapy method applied by making are associated with art therapy practices or involvement
and using art in many visual, auditory and physical means. in a group psychotherapy process. They suggested that
The American Art Therapy Association defines art therapy it would be beneficial to compare the methods through
as “an integrative mental health and human services group works using different psychotherapy techniques and
profession that enriches the lives of individuals, families, and to evaluate the differences in psychotherapy methods for
communities through active art-making, creative process, schizophrenia patients (Sarandöl et al. 2013). From this
applied psychological theory, and human experience within point of view, this study investigated the effects of the PSST
a psychotherapeutic relationship” (American Art Therapy and art therapy group works added to drug therapy on the
Association AATA, 2017). The purpose of art therapy is symptoms and personal and social skills of the randomized
to improve an individual’s creativity, emotional expression, schizophrenia patients, and whether there were differences
communication, and ability to relate to oneself and others. in the effects observed on patients between the groups.
Art therapy is an effective therapy, especially for those who Relatives of patients were also included in the study due
have difficulty expressing their feelings and thoughts verbally, to the importance and positive effect of family members’
such as individuals with schizophrenia. It facilitates the participation in the treatment of schizophrenia patients.
connection between conscious and unconscious processes Thus, we aimed to inform the relatives of patients about
and allows individuals to become aware of and reveal schizophrenia, raise awareness about the factors affecting
themselves (Patterson 2007). The use of artistic elements the course of the disease and its individual and social
such as painting, music, clay and drama helps to externalize consequences, provide a basis for a healthy relationship with
unspoken feelings and thoughts (Killick and Schaverien
patients, and allow them to keep their expectations from the
2003). Art is considered a medium that offers patients a
patient at a realistic level, communicate with other patient
secure and indirect way of connecting with themselves and
relatives to share experiences, and monitor the changes in
others. Creating artworks and sharing this process has an
the patient more closely.
inherent therapeutic effect (Sarandöl et al. 2013). Some
studies on the effectiveness of art therapy in the treatment of
schizophrenia patients showed its positive effects on positive
METHOD
and negative symptoms, social functionality, interpersonal
communication, depressive symptoms and medication Forming the Study Groups and Procedure
management (Patterson 2007).
An approval (no. B.30.ULU.0.20.11.05-604.01.01/1189
Families of patients with schizophrenia have important dated 01/03/2016) was obtained from Bursa Uludağ
roles in the treatment, follow-up and social adaptation University Ethics Committee. Written informed consent was
of patients. Yıldız et al. (2003) applied a rehabilitation obtained from the patients and their relatives. Study sample
program to schizophrenia outpatients with the participation consisted of 15 patients diagnosed with schizophrenia
of volunteers and their families, and observed that there according to DSM-5 monitored in the Psychosis Outpatient
was an improvement in the clinical condition and social Clinic of Mental Health and Diseases Department of Faculty
functionality of the patients at the end of the program. of Medicine, Bursa Uludağ University (B.U.Ü.T.F) and
Considering the chronic course of schizophrenia and its 12 patient relatives. The patients were monitored by two
consequential difficulties, it is important that families as physicians in the psychosis outpatient clinic. To eliminate
the caregivers of the patients are informed about the nature therapist bias, the patients participated in group works
of the disease and coping methods and able to choose with physicians who did not monitor them. The patients
treatment. In addition, the mental status of families should were randomized into 2 groups, 7 of them being included
be monitored to maintain their well-being, and appropriate in the art therapy group, and 8 of them being included
interventions should be made when necessary. It is known in the PSST program for schizophrenia. Art therapy and

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PSST practices consisted of 90-minute sessions once a week attention and memory problems, understanding psychosis
for 17 weeks. The PSST program was applied to separate and schizophrenia, learning about antipsychotic medication,
groups of patients and relatives simultaneously, while the learning about medication side effects, evaluating the
patients and relatives in the art therapy group received treatment, learning to cope with persistent symptoms,
the first 5 sessions in separate groups and then continued recognizing and monitoring warning signs, learning about
next sessions in the same group. Patients and relatives were the negative effects of alcohol and narcotic drugs to avoid
gathered in the same group after the fifth session to avoid them, avoiding seeking useless treatments, learning to cope
any methodological differences from the art therapy study with stress, increasing self-confidence, recreation and daily
we conducted in 2013 (Sarandol et al., 2013). Individual activities, improving friendship, and participating in social
preliminary interviews were conducted with patients and activities. Skill acquisition was achieved gradually with
relatives to obtain sociodemographic information and to small steps. The training used active teaching methods
evaluate psychiatric conditions. The patients and relatives such as setting a purpose, informing, being a model,
were informed about the group works and the objectives of behavioral rehearsing, role playing, supporting the desired
the study. Sociodemographic and clinical characteristics of response, giving corrective feedback, behavior shaping,
15 patients are shown in Table 1. sharing experiences, using appropriate social enhancements,
reinforcement with exercises and homework, and informing
The inclusion criteria of the study were to be at the ages of 18
the families.
to 65, to be diagnosed with schizophrenia according to DSM-
5, to be literate, to have completed the acute therapy and be on The patients included in group works continued their routine
maintenance medication, and to give consent to participate in treatment and monitoring in our psychosis outpatient clinic.
group training after being informed. The exclusion criteria During the period of group works and scale evaluations, none
were to be in a psychotic exacerbation period, to have an of the patients were hospitalized and no changes were made
organic mental disorder or mental retardation, and to have to the current medications.
alcohol/substance use disorder.
Art therapy group works were conducted as closed group Scales Used in the Study
works and in 17 sessions in total. In the first year, the study The patient group was applied the Positive and Negative
lasted 12 weeks, and the next 5 sessions were reserved for Syndrome Scale (PANSS), Calgary Depression Scale for
theater play rehearsals. Sessions lasted 90 minutes. Each Schizophrenia (CDSS), Social Functioning Scale (SFS),
session consisted of 2 parts. In the first five sessions, the Hinting Task (HT), Unexpected Outcomes Test (UOT), and
patients and relatives studied in separate groups but did the relatives of the patients were applied Zarit Burden Interview
same activities. The intention was to ensure that the patients (ZBI), Beck Depression Inventory (BDI) and Beck Anxiety
and relatives get help primarily for themselves in separate Inventory (BAI) before the group works, and 3, 6 and 12
groups. For the purposes of the study, the relatives of the
months after the end of the group works to measure the long-
patients would be effective in the development of the personal
term effects.
and social skills of the patients, therefore they were included
in the patient group after the fifth session, together forming Positive and Negative Syndrome Scale (PANSS): It is used
a large group. This allowed for synergy in functionality to measure the distribution and severity of positive and
between the two groups. Group sessions included elements negative symptoms in schizophrenia. It was developed by
of painting, music, literature, clay and theater. In each Kay et al. (1987). It consists of 30 items and each item has
session, before the practice, the members shared about the a severity rating of 1-7. PANSS is a Likert-type scale. The
previous practice and their daily life for the last week. It was validity and reliability study of the Turkish version of the scale
followed by a practice with an art material, personal and was performed by Kostakoğlu et al. (1999). Concerning the
group feedbacks were received about the resulting product internal consistency, Cronbach’s alpha coefficients were high
of the practice, and they shared feelings and thoughts about (0.75, 0.77 and 0.71, respectively), similar to the original
the whole process. Finally, the relationship and differences study. The inter-rater reliability correlation coefficients
with daily life of the shared experiences were emphasized. for the subscales were 0.97, 0.96 and 0.91, respectively.
Therapists also provided feedback as needed. After the first For construct validity, the correlation coefficient between
year, group works were continued in the second year once subscales was found to be -0.41, showing that positive and
every 15 days. negative subscales measured different symptom clusters,
similar to the original study.
The skills that the schizophrenia patients received training in
the PSST program were: improving communication skills, Calgary Depression Scale for Schizophrenia (CDSS): This
improving problem-solving skills, learning to cope with test was developed by Addington et al. (1992) to measure

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the level and severity of depressive symptoms in patients 10 short stories between two characters and these stories are
with schizophrenia. The validity and reliability study of read out by the researcher. Every story ends with one of the
the Turkish version of the scale was performed by Aydemir characters hinting something to the other. The participant is
et al. (2000). The internal consistency of CDSS was high asked what the character really meant to say. An appropriate
(Cronbach’s alpha coefficient 0.90). Inter-rater reliability response in the first step takes 2 points. If the correct meaning
coefficient (0.87-1) and test-retest reliability (0.95-1) were is not inferred, the story continues and a more obvious hint
statistically significant. CDSS is a four-point Likert scale is given. If the participant gives a correct answer at this stage,
rated by the interviewees and consists of 9 items. Each item he/she gets 1 point, if he/she does not answer correctly, he/she
on the scale is scored between 0-3 points and the total score gets 0 points and goes on to the next story. The total points
is between 0-27. range from 0 to 20. The test is used to evaluate theory of
mind deficits in patients with schizophrenia (Bora et al. 2008,
Social Functioning Scale (SFS): It was developed by Tas et al. 2012).
Birchwood et al. (1990), and validity and reliability studies
of its Turkish version were performed by Erakay (2001). Unexpected Outcomes Test (UOT): This test, consisting
In the reliability analysis of the scale, Cronbach’s alpha of 12 questions, was developed by Dyck et al. (2001) to
internal consistency coefficient was 0.807, and the reliability measure the ability to think logically, the emotions elicited
coefficient between patients and relatives was 0.95. It consists by the overall situation, and the ability to understand the
of 7 domains: social withdrawal, interpersonal functioning, inconsistency between the emotion and the emotion-eliciting
pro-social activities, recreation, independence-competence, situation. UOT items describe a situation that can cause an
independence-performance, employment. ordinary emotional response in the character and indicate the
character’s emotional response. In each question, the emotion
Zarit Burden Interview (ZBI): It was developed by Zarit et is something unexpected arising in these situations. The person
al. (1980). The validity and reliability studies of its Turkish being tested is asked to provide additional information about
version were performed by Özlü (2004). The Cronbach’s the context to explain the apparent discrepancy. Answers are
alpha internal consistency coefficient of the scale was 0.83. recorded in the test booklet and scored on a three-point (0-2)
It is used to determine the level of the social and economic scale. The test is ended if incorrect answers are given three
burden on the caregivers. The total score ranges from 22 to times consecutively. The total score ranges from 0 to 24. In
110. The scores are evaluated as ‘mild burden’ at a score of the pilot study conducted for the Turkish version of the test,
22-46, ‘moderate burden’ at 47-55, and ‘severe burden’ at the inter-rater reliability was found 0.91 and its validity was
56-110. also shown (Bora, 2009).
Beck Depression Inventory (BDI): It was originally
developed by Beck et al. (1961) and adapted into Turkish Evaluation
by Hisli (1989). The split-half test reliability coefficient was Both groups of patients who received art therapy and PSST
0.74. The criterion validity between the Multidimensional were evaluated using PANSS, CDSS, SFS, UOT before
Personality Questionnaire-Depression Scale was 0.63. the training (0 month) and 3, 6 and 12 months after the
The person filling out this self-assessment scale marks the training.
sentence that best expresses how they felt in the previous
week, including the day of the application. Each item is Patient relatives who received art therapy and PSST were
scored between 0-3. The highest possible score is 63. Scores evaluated using BAI, BDI, and ZBI before the training (0
of 0 to 9 are evaluated as no/minimal depression, 10 to 18 month) and 3, 6 and 12 months after the training.
as mild depression, 19 to 29 as moderate depression, and 30
to 63 as severe depression. Statistical Evaluation

Beck Anxiety Inventory (BAI): It was developed by Beck et The Shapiro-Wilk test was used to examine whether the
data showed a normal distribution. Descriptive statistics
al. (1988) and adapted into Turkish by Ulusoy et al. (1993).
were presented as mean and standard deviation or median
Ulusoy et al. found the Cronbach’s alpha internal consistency
(minimum-maximum) for quantitative data, and as frequency
coefficient of the scale to be 0.93. BAI is a self-assessment scale
and percentage for qualitative data. The t-test was used for
used to determine the level of anxiety, symptom distribution
the comparison of two groups for normally distributed data,
and severity. It is scored is between 0-63. Scores of 8 to 15 are
and the Mann-Whitney U test was used for the comparison
considered as mild anxiety, 16 to 25 as moderate anxiety, and
of two groups for data that was not normally distributed.
26 to 63 as severe anxiety.
The analysis of the difference between groups for repeated
Hinting Task (HT): It is one of the advanced theory of mind measurements was made over the changes calculated from
tests developed by Corcoran et al. (1995). The test consists of the initial measurement. Variance analysis of repeated

105
measurements and Friedman’s test were used to compare the age, marital status, education level, employment, age of the
time-dependent measurements of the variables within the first episode, number of episodes, number of hospitalizations,
group. In case of significance, Bonferroni test was used in suicide history, and family history. The sociodemographic
pairwise comparisons. The significance level was determined characteristics of the participants are shown in Table 1.
as p≤0.05. Statistical analysis of data was performed using
SPSS23.0 (IBM Corp. Released 2015. IBM SPSS Statistics Comparison of the Scales Applied to the Patients
for Windows, Version 23.0. Armonk, NY: IBM Corp.) Before and After the Group Works
statistical package program. In PSST group, no statistically significant difference was
found in the comparison of positive symptoms subscale of
RESULTS PANSS and social withdrawal, interpersonal functionality,
recreation, employment subscale scores of CDSS, HT, UOT,
Comparison of both patient groups in sociodemographic and SFS gathered before the group works (0 month) and at 3,
characteristics revealed no significant difference in gender, 6 and 12 months after the end of the group works.

Table 1. Sociodemographics of Patients

Art Therapy Group PSST Group p

Age (mean±SD) 44±6.92 41.62±7.28 0.531

Gender (n, %) 0.282

Male 4 (57.2%) 7 (87.5%)

Woman 3 (42.8%) 1 (12.5%)

Marital Status (n, %) -

Married 0 (0%) 0 (0%)

Single 7 (100%) 8 (100%)

Education (n, %) 0.569

Primary school 0 (0%) 1 (12.5%)

Secondary school 1 (14.28%) 1 (12.5%)

High school 4 (57.14%) 5 (62.5%)

Higher education 0 (0%) 1 (12.5%)

University 2 (28.57%) 0 (0%)

Employment (n, %) 0.467

Employed 1 (14.28%) 0 (0%)

Retired 0 (0%) 2 (25%)

Unemployed 6 (85.72%) 6 (75%)

Suicide history (n, %) 0.467

Yes 0 (0%) 2 (25%)

No 7 (100%) 6 (100%)

Family history (n, %) 1

Yes 3 (42.8%) 4 (50%)

No 4 (57.2%) 4 (50%)

Age at first episode (mean, SD) 22.71±5.28 23.62±6.9 0.781

Number of episodes (mean, SD) 2.42±1.9 3±3.09 0.955

Number of hospitalizations (mean, SD) 1.57±0.78 1.62±1.50 0.867

PSST: Psychosocial Skills Training

106
 Table 2. Changes in the Scales with Significant Differences for the Art Therapy and PSST Groups

Art Therapy Group 0 month 3 months 6 months 12 months p

PANSS - Negative Symptoms 20.86±4.30a 19.00±2.71a 16.86±5.46a,b 12.29±1.50b 0.001

PANSS - General Psychopathology 28.43±6.24a 29.71±6.58a 25.29±3.09a 19.29±3.15b 0.001

PANSS – Total 60.00±12.40a 60.43±11.82a 52.71±5.71a 40.71±5.44b <0.001

SFS - Social Withdrawal 10.29±1.60a 10.14±1.46a 11.29±2.06a,b 12.43±1.72b 0.008

SFS - Pro-Social Activities 9.14±3.80a 8.57±3.64a 10.29±6.10a 16.86±2.67b <0.001

SFS – Level of Independence (Competence) 35.00±2.77a 35.29±4.19a,b 36.86±1.46a,b 38.00±1.53b 0.033

SFS – Level of Independence (Performance) 23.29±4.27a 25.14±6.52a 26.29±7.02a 29.29±5.79a 0.036

PSST Group

PANSS - Negative Symptoms 20.88±4.85a 21.38±10.80a 17.13±8.20a 15.88±6.96a 0.047

PANSS - General Psychopathology 34.00±6.14a 33.25±6.45a 23.38±6.52b 23.88±5.11b <0.001

PANSS – Total 67.50±11.31a 67.13±15.72a 53.38±13.32a,b 51.25±12.43b 0.001

SFS - Pro-Social Activities 9.50±3.16a 9.50±3.16a 9.50±1.77a 10.00±1.31a 0.021

SFS – Level of Independence (Competence) 33.38±5.34a 34.50±4.99a,b 36.25±4.80b 36.38±4.50b 0.005

SFS – Level of Independence (Performance) 18.13±5.67a 19.00±9.17a 21.13±8.98a 22.88±11.52a 0.039

a, b superscripts indicate statistical differences between groups in the same row. There is no statistically significant difference between the months with the same superscripts.
PSST: Psychosocial Skills Training
PANSS: Positive and Negative Syndrome Scale
SFS: Social Functioning Scale

In art therapy group, there was no statistically significant There was no statistically significant difference between art
difference in the comparison of positive symptoms subscale therapy and PSST groups in the comparison of the PANSS,
of PANSS and interpersonal functionality, recreation, CDSS, SFS, HT, and UOT scores for before the group
employment subscale scores of CDSS, HT, UOT, and SFS works (0 month), and 3, 6 and 12 months after the end of
gathered before the group works (0 month) and 3, 6 and 12 the group works. Table 4 presents detailed information.
months after the end of the group works.
Subscales with significant differences in intra-group Comparison of Scales Applied to the Relatives of
comparison of scores for before and after the art therapy and Patients Before and After the Group Works
PSST group works with patients are shown in Table 2, Figures There was no significant difference between art therapy and
1a and 1b. PSST groups of patient relatives upon the examination of
There was a significant difference in the total score of the changes in the BAI, BDI, and ZBI scores for before the
the PANSS negative symptoms subscale in intra-group group works and at 3, 6 and 12 months after the end of
assessment of both the art therapy and PSST groups, the group works. There was also no significant difference in
therefore the items of the negative symptoms scale were the scale scores between the groups of relatives of patients.
reviewed one by one. The changes in PANSS negative Intra-group and inter-group comparison of the scale results
symptoms subscale items for both study groups are shown of the patient relatives who received art therapy and PSST
in Table 3 and Figure 2. is shown in Table 5.

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 100 PANSS-Negative Symptoms
PANSS-General Psychopathology
80 PANSS-Total

ART THERAPY GROUP

60

40

20

0
PANSS

100

80

60

PSST
40

20

0
0. month 3. months 6. months 12. months

The data are distributed within the 95% confidence interval.

Figure 1a. Changes in the Scales with Significant Differences for the Art Therapy and PSST Groups
PSST: Psychosocial Skills Training
PANSS: Positive and Negative Syndrome Scale

50 SFS-Social Withdrawal
SFS-Pro-Social Activities
SFS-Independence-competence
40
SFS-Independence-performance
ART THERAPY

30

20

10
SFS

50

40

30
PSST

20

10

0. month 3. months 6. months 12. months

The data are distributed within the 95% confidence interval.

Figure 1b. Changes in the Scales with Significant Differences for the Art Therapy and PSST Groups
PSST: Psychosocial Skills Training
SFS: Social Functioning Scale

108
 Table 3. Changes in the PANSS Negative Symptoms Subscale Items for Both Study Groups

Art Therapy Group 0 month 3 months 6 months 12 months p

PANSS - Negative Symptoms

Blunted Affect 2.71±0.488 2.57±0.535 2.57±0.787 2.00±0.00 0.087

Emotional Withdrawal 3.00±1.00 2.86±0.378 2.86±1.345 2.29±0.488 0.199

Difficulty Building Relationships 2.57±0.535 2.86±0.69 2.57±0.976 1.71±0.756 0.091

Passive Social Withdrawal 3.43±0.976a 2.86±0.378a 2.71±0.756a,b 1.71±0.756b 0.004*

Abstract Thinking Difficulty 3.29±1.113a 3.00±0.577a 1.71±0.756b 2.00±0.816a,b 0.006*

Loss of Spontaneity and Flow of Conversation 2.86±0.690a 3.00±0.577a 2.57±0.976a 1.29±0.488b 0.005*

Stereotypical Thinking 3.00±0.816a 2.29±0.756a,b 1.86±0.9a,b 1.29±0.488b 0.012*

PSST Group

PANSS - Negative Symptoms

Blunted Affect 3.00±1.195 3.00±1.852 2.38±1.506 2.50±0.926 0.277

Emotional Withdrawal 2.63±1.061 3.00±1.852 2.75±1.488 2.38±0.916 0.753

Difficulty Building Relationships 3.13±0.835 3.38±1.685 2.75±1.282 2.38±1.061 0.069

Passive Social Withdrawal 3.50±0.535 3.13±1.553 2.75±1.389 2.50±1.195 0.222

Abstract Thinking Difficulty 2.88±0.991a 3.25±1.389a 2.25±1.389a,b 2.13±1.246a,b 0.014*

Loss of Spontaneity and Flow of Conversation 3.00±1.195 3.00±1.512 2.75±1.488 2.13±1.246 0.155

Stereotypical Thinking 2.63±1.061 2.63±1.685 1.50±0.756 2.00±1.069 0.132

a, b superscripts indicate statistical differences between groups in the same row. There is no statistically significant difference between the months with the same superscripts.
PSST: Psychosocial Skills Training
PANSS: Positive and Negative Syndrome Scale

5 Blunted affect
Emotional Withdrawal
Difficulty Building Relationships
4 Passive Social Withdrawal
ART THERAPY

Abstract Thinking Difficulty

3 Loss of Spontaneity and Flow of Conversation
Stereotypical Thinking
2

0
5

3
PSST

0. month 3. months 6. months 12. months

Figure 2. Changes in the PANSS Negative Symptoms Subscale Items for Both Study Groups
PANSS: Positive and Negative Syndrome Scale

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 Table 4. Comparison of Scale Scores Between the Groups of Art Therapy and PSST

Art Therapy Group PSST Group p

0 month 10.71 ± 5.61 12.62 ± 6.23 0.546
3 months ∆ 13.14 ± 6.26 12.5 ± 6.8 0.258
0.29 ± 0.41 0.04 ± 0.39
PANSS - Positive Symptoms 6 months ∆ 10.57 ± 3.64 12.88 ± 5.49 0.797
0.07 ± 0.33 0.11 ± 0.37
12 months ∆ 9.14 ± 2.48 11.5 ± 5.40 0.795
0.07 ± 0.17 0.04 ± 0.22
0 month 20.85 ± 4.29 20.87 ± 4.85 0.994
3 months ∆ 19 ± 2.71 21.38 ± 10.8 0.658
0.069 ± 0.15 0.0009 ± 0.37
PANSS - Negative Symptoms 6 months ∆ 16.86 ± 5.46 17.13 ± 8.2 0.914
0.16 ± 0.307 0.186 ± 0.301
12 months ∆ 12.29 ± 1.5 15.88 ± 6.86 0.124
0.393 ± 0.116 0.249 ± 0.203
0 month 28.42 ± 6.24 34 ± 6.141 0.106
3 months ∆ 29.71 ± 6.58 33.25 ± 6.45 0.559
0.758 ± 0.323 0.007 ± 0.21
PANSS - General Psychopathology 6 months ∆ 25.29 ± 3.09 23.28 ± 6.52 0.051
0.775 ± 0.299 0.204 ± 0.195
12 months ∆ 19.29 ± 3.15 23.88 ± 5.11 0.856
0.305 ± 0.11 0.294 ± 0.11
0 month 60 ± 12.39 67.5 ± 11.31 0.242
3 months ∆ 60.43 ± 11.82 67.13 ± 15.72 0.839
0.023 ± 0.21 0.21 ± 0.215
PANSS – Total 6 months ∆ 52.71 ± 5.71 53.38 ± 13.32 0.237
0.09 ± 0.195 0.206 ± 0.166
12 months ∆ 40.71 ± 5.44 51.25 ± 12.43 0.281
0.308 ± 0.096 0.243 ± 0.121
0 month 1.142 ± 1.573 3.13 ± 3.76 0.218
3 months ∆ 1.57 ± 2.15 2.5 ± 3.85 0.609
0.42 ± 2.93 0.62 ± 4.53
CDSS 6 months ∆ 0.86 ± 1.21 1.13 ± 1.73 0.248
0.28 ± 1.70 2 ± 3.38
12 months ∆ 1.29 ± 1.6 1.13 ± 1.36 0.104
0.14 ± 1.57 2 ± 2.87
0 month 10.28 ± 1.6 9.12 ± 2.1 0.256
3 months ∆ 10.14 ± 1.46 9.5 ± 3.16 0.748
0.14 ± 1.77 0.37 ± 3.81
SFS - Social Withdrawal 6 months ∆ 11.29 ± 2.06 9.5 ± 1.77 0.616
1±2 0.37 ± 2.61
12 months ∆ 12.43 ± 1.72 10 ± 1.31 0.232
2.14 ± 1.95 0.87 ± 1.95
0 month 5 ± 1.82 4 ± 1.77 0.302
3 months ∆ 4.71 ± 1.38 4.38 ± 2.2 0.452
0.28 ± 1.97 0.37 ± 1.302
SFS - Interpersonal Relationships 6 months ∆ 5.14 ± 1.68 4.88 ± 2.53 0.499
0.14 ± 2.03 0.87 ± 2.03
12 months ∆ 4.71 ± 0.76 5.13 ± 1.81 0.078
0.28 ± 1.38 1.12 ± 1.45

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Continuation of Table 4

Art Therapy Group PSST Group p

0 month 9.14 ± 3.8 8 ± 2.82 0.517
3 months 8.57 ± 3.64 6.88 ± 4.29 0.803
∆ 0.57 ± 3.1 1.12 ± 4.94
SFS - Pro-Social Activities 6 months 10.29 ± 6.1 9.25 ± 4.4 0.962
∆ 1.14 ± 3.23 1.25 ± 5
12 months 16.86 ± 2.67 13.38 ± 6.65 0.458
∆ 7.71 ± 2.42 5.37 ± 7.72
0 month 14.85 ± 4.63 11 ± 3.33 0.084
3 months 13.29 ± 3.25 11.38 ± 4.24 0.311
∆ 1.57 ± 3.9 0.37 ± 3.24
SFS - Recreation 6 months 13.29 ± 2.06 11.63 ± 2.92 0.266
∆ 1.57 ± 3.35 0.62 ± 3.88
12 months 14.57 ± 3.41 11.13 ± 3.23 0.819
∆ 0.28 ± 3.72 0.12 ± 3.09
0 month 35 ± 2.76 33.37 ± 5.34 0.483
3 months 35.29 ± 4.19 34.5 ± 4.99 0.427
∆ 0.006 ± 0.063 0.041 ± 0.097
SFS - Independence (Competence) 6 months 36.86 ± 1.46 36.25 ± 4.8 0.420
∆ 0.05 ± 0.05 0.09 ± 0.12
12 months 38 ± 1.53 36.38 ± 4.5 0.820
∆ 0.08 ± 0.07 0.09 ± 0.06
0 month 23.28 ± 4.27 18.12 ± 5.66 0.071
3 months 25.14 ± 6.52 19 ± 9.17 0.673
∆ 1.85 ± 4.74 0.87 ± 4.08
SFS - Independence (Performance) 6 months 26.29 ± 7.02 21.13 ± 8.98 1
∆ 3 ± 4.96 3 ± 4.5
12 months 29.29 ± 5.79 22.88 ± 11.52 0.683
∆ 6 ± 5.22 4.75 ± 6.2
0 month 1.71 ± 1.7 1.62 ± 1.06 0.903
3 months 1.14 ± 1.07 1.63 ± 2.39 0.566
∆ 0.57 ± 1.39 0 ± 2.20
SFS - Employment 6 months 1.43 ± 0.98 1.25 ± 1.39 0.903
∆ 0.28 ± 1.25 0.37 ± 1.5
12 months 1.86 ± 1.46 1.13 ± 1.25 0.449
∆ 0.14 ± 1.67 0.50 ± 1.51
0 month 12.28 ± 6.72 11.75 ± 5.92 0.872
3 months 13.29 ± 2.29 12 ± 5.01 0.741
∆ 1 ± 4.96 0.25 ± 3.61
Hinting Task 6 months 14.86 ± 3.13 11.25 ± 6.23 0.222
∆ 2.57 ± 5.99 0.50 ± 2.97
12 months 16.14 ± 2.79 13.75 ± 5.37 0.416
∆ 3.85 ± 4.74 2 ± 3.81
0 month 15.85 ± 2.11 12.12 ± 7.84 0.232
3 months 17.14 ± 3.48 13.63 ± 8.53 0.898
∆ 1.28 ± 3.59 1.5 ± 2.72
6 months 18.57 ± 3.21 13.63 ± 8.28 0.241
∆ 2.71 ± 1.79 1.5 ± 2
Unexpected Outcomes Test
12 months 17.71 ± 2.36 11.88 ± 7.04 0.228
∆ 1.85 ± 2.41 0.25 ± 3.77
“∆” symbol indicates the change compared to the initial measurement (0 month).
PSST: Psychosocial Skills Training, PANSS: Positive and Negative Syndrome Scale, CDSS: Calgary Depression Scale for Schizophrenia, SFS: Social Functioning Scale

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 Table 5. Intra-Group and Intergroup Comparison of the Scale Results of the Relatives of the Patients Received Art Therapy and PSST
Art Therapy Group PSST Group p
0 month 8.6 ± 7.16 7.57 ± 4.82 1.0
3 months 10.4 ± 5.94 8.42 ± 3.90 0.755

∆ 1.8 ± 2.05 0.86 ± 3.76

BECK-D
6 months 9.2 ± 3.76 9 ± 5.44 0.755
∆ 0.6 ± 6.91 1.43 ± 3.51
12 months 12.4 ± 7.7 14.42 ± 13.86 0.876

∆ 3.8 ± 3.63 6.86 ± 11.28

0 month 7 ± 6.96 7.42 ± 7.61 1.0
3 months 10.6 ± 9.2 7.71 ± 5.99 0.106
∆ 3.6 ± 2.41 0.29 ± 3.59
BECK-A
6 months 12.6 ± 11.92 7.85 ± 4.87 0.343
∆ 5.6 ± 5.37 0.43 ± 6.43
12 months 13.4 ± 14.08 7.42 ± 4.42 0.149
∆ 6.4 ± 7.4 0.0 ± 6.66

0 month 44.8 ± 13.8 46 ± 11.06 0.106

3 months 44.8 ± 6.97 48.57 ± 18.36 0.755
∆ 0.0 ± 11.47 2.57 ± 12.46
ZBI
6 months 42.8 ± 10.73 44.14 ± 16.21 0.53

∆ -2.0 ± 13.44 -1.86 ± 18.12

12 months 47 ± 14.89 43.14 ± 15.88 0.53
“∆” symbol indicates the change compared to the initial measurement (0 month).
PSST: Psychosocial Skills Training
BECK-D: Beck Depression Inventory
BECK-A: Beck Anxiety Inventory
ZBI: Zarit Burden Interview

DISCUSSION all evaluated months and the 12th month, as well as in the
independence level subscale of the SFS when the results from
The most appropriate approach in the treatment of baseline, 6 months and 12 months were compared. Only the
schizophrenia is the integration of drug therapy into various abstract thinking difficulty subscale of the negative symptoms
unique psychological and social interventions and methods of the PANSS scale showed a significant difference. In art
(Falloon et al. 1998). From this point of view, this study therapy and PSST groups, there was no significant difference
included schizophrenia patients who were monitored regularly between the groups in the results of all the scales applied to
in the Psychosis Outpatient Clinic of the Department the patients and relatives before the group works and 3, 6
of Mental Health and Diseases of B.U.Ü.T.F., and they and 12 months after the end of the group works. There are
participated in different PSST and art therapy works in two few studies in this area that applied art therapy or PSST in
groups, in addition to drug therapy. Evaluation of the scales schizophrenia patients in group works. To the best of our
applied in the art therapy group revealed that positive changes knowledge, this is the first study to compare the effects of
started in PANSS negative symptoms from the 3rd month, art therapy and PSST methods in two different groups of
and there were significant changes in passive withdrawal, schizophrenia patients.
abstract thinking difficulty, loss of spontaneity and flow of Both programs aimed to reduce the severity of symptoms,
conversation. SFS evaluation showed a significant difference improve interpersonal skills, increase their daily functionalities
in the social withdrawal subscale between the months starting and quality of life, and establish a healthy communication
from the 3rd month, as well as in pro-social activities and ground with the families. Both programs helped patients
independence level subscales between the baseline and express themselves and make sense of their experiences,
12-month scores. In PSST group, there was a significant improve their ability to understand others, and enabled them
change in the PANSS general psychopathology score between to become aware of biased thoughts and create alternative

112
thoughts, and participate in social relationships and increase was determined that the group receiving combination therapy
social functionality (Sarandöl et al. 2013, Yıldız et al. 2019). had significantly lower PANSS scale scores.
The improvement observed in scores of negative symptoms
In our study, positive symptoms and depression scales
subscale of PANSS and SCQ subscales in the members of
applied before and after art therapy and PSST group works
both therapy and PSST groups was also consistent with
previous studies (Deveci et al. 2008, Sarandöl et al. 2013). were compared, and no significant difference was found
between them. There was also no significant difference
Teglbjaerg et al. (2011) applied art therapy to 5 schizophrenia before and after group works in the depression, anxiety
patients for 1 year and showed that psychotic symptoms had and caregiver burden scales applied to the relatives of the
decreased, self-esteem had increased, and social functionality patients. These results may be associated with the fact that
had improved when results from before and after therapy, and the patients included in the study were being monitored in
results from a 1-year follow-up were compared. Another study a specialized outpatient clinic, so more time was allocated
investigated the effects of motivation interviewing together to these patients compared to the general psychiatry
with art therapy group works on the negative symptoms of outpatient clinic monitoring, and the monitoring and
schizophrenia patients in which 18 schizophrenia patients treatment of the patients by the same physician might have
received only art therapy and 17 schizophrenia patients allowed the treatment processes of the patients to be well
received art therapy combined with motivation interviewing managed. In addition, it may be associated with provision of
for 6 weeks. It was observed that there were significantly psycho-education to patients and their relatives, immediate
more improvements in negative symptoms, motivation and intervention in additional psychiatric conditions such
pleasure, interpersonal relationships, personal hygiene, and as drug adverse effects and depression, and supportive
attendance to the hospital program in the group that had interviews with patients’ relatives.
motivation interviewing together with art therapy compared
to the art therapy group alone (Cho and Lee 2018). It was emphasized in previous psychosocial intervention
studies with schizophrenia patients that the positive changes
Meng et al. (2005) randomly divided 86 inpatients into
observed might be related to the methods used, as well as
intervention and control groups, applied art therapy
the participation of patients and their relatives in a regular
twice a week to the intervention group for more than 15
group psychotherapy process (Sarandol et al. 2013, Yıldız et
weeks, and reported improvement in quality of life, self-
al. 2002). Therefore, one of the main objectives of this study
esteem and social functionality at the end of this period
was to compare two different psychosocial intervention
compared to the control group. Richardson et al. (2007)
methods. We found differences in intra-group evaluations
randomized outpatient chronic schizophrenia patients into
although there was no difference between the two groups.
two groups to compare 47 patients who received standard
In this study, patient relatives in both groups participated in
drug therapy and 43 patients who received 12 weeks of
art therapy in addition to standard therapy. Among 40 the process. The relatives were in the same group with the
participants who were followed up for another six months patients from the beginning of the practices in the PSST
after the therapy sessions, art therapy had a statistically group, while the relatives in the art therapy were in different
significant positive effect on negative symptoms. Sarandöl groups until session 5, and joined the same group with the
et al. (2013) investigated the effects of art therapy applied patients in the next sessions. The reason why the patients
by schizophrenia patients and their relatives on disease and their relatives joined each other after session 5 in the
symptoms and personal and social skills, and it was found art therapy group was that we also used the same method in
out that according to the scale evaluation before and after the art therapy study in 2013 (Sarandöl et al., 2013), and
group works, the PANSS negative symptoms, PANSS we tried to allow for no methodological differences between
general psychopathology and CDSS scores in the patient the two studies to ensure continuity. Considering the data
group as well as BDI, BAI, ZBI scores in the relatives group obtained, it can be suggested that this method created a
were statistically significantly lower after group works. significant difference.

Deveci et al. (2008) applied PSST to patients with schizophrenia This study is important in the evaluation of the effects of art
and observed significant decreases in the scores of the Scale for therapy and PSST in the treatment of schizophrenia. The
the Assessment of Positive Symptoms (SAPS), Scale for the limitations of our study are that it was conducted in a single
Assessment of Negative Symptoms (SANS), Schizophrenia healthcare center, included a small number of patients, had
Quality of Life Scale (SQLS), and CDSS. Moriana et al. no control group, and did not compare the drug therapies of
(2006) treated 32 of 64 schizophrenia patients with only the patients, which makes it difficult to generalize the data
medication, and applied PSST to 32 of them in addition to a obtained. Studies with larger samples and involving multiple
6-month drug therapy. The two groups were compared, and it healthcare centers are needed.

113
It can be asserted that the patients in both study groups Corcoran R, Mercer G, Frith CD (1995) Schizophrenia, symptomatology and
social inference: investigating theory of mind in people with schizophrenia.
benefited from the therapy methods applied, considering Schizoph Res 17: 5-13.
the decrease in the scale scores. Schizophrenia was regarded Danacı AE, Karaca N, Deveci A (2005) Şizofreni hastalarında aile işlevselliği ile
as a biological disease for a long time, which caused sosyal işlevsellik arasındaki ilişkinin değerlendirilmesi. Türkiye’de Psikiyatri
psychotherapeutic practices to be overlooked. However, 7: 103-8.
Deveci A, Danacı AE, Yurtsever F et al. (2008) Şizofrenide psikososyal beceri
both the biological basis of the disease and some drugs cause eğitiminin belirti örüntüsü, içgörü, yaşam kalitesi ve intihar olasılığı üzerine
social and cognitive problems in patients. Obviously, it is an etkisi. Türk Psikiyatri Derg 19: 266-73.
overly optimistic approach today to hope that these problems Dyck MJ, Ferguson K, Shochet IM (2001) Do autism spectrum disorders differ
can only be treated with drugs. We think that all of the from each other and from non-spectrum disorders on emotion recognition
tests? Eur Child Adolesc Psychiatr 10: 105-16.
psychotherapy methods used for this purpose are valuable,
Erakay SY (2001) Investigation of the validity and reliability of the Turkish
and investigated whether there are differences between the version of the Social Functioning Scale (SSQ) in patients with schizophrenia.
methods. The finding that both methods have benefits but Unpublished thesis.
there is no difference in terms of benefit between them may Falloon IR, Held T, Roncone R et al. (1998) Optimal Treatment Strategies To
Enhance Recovery From Schizophrenia. Aust N Z J Psychiatry 32: 43-9.
have arisen from the limitations of the study, or it may be the
Friedmann MS, McDermut WH, Solomon DA et al. (1997) Family functioning
truth itself. and mental illness: a comparison of psychiatric and nonclinical families.
Fam Process 36: 357-67.
In conclusion, this study found that both art therapy and PSST Hisli N (1989) Beck Depresyon Envanteri’nin üniversite öğrencileri için
practices allowed patients with schizophrenia to improve the geçerliği, güvenirliği. Psikoloji Dergisi 7: 3-13.
negative symptoms such as decreased social and cognitive Kay SR, Fiszbein A, Opler LA (1987) The Positive and Negative Sydrome Scale
functionality. However, there is a need for longer-term studies (PANSS) for schizophrenia. Schizophr Bull 13: 261-76.

that compare different mental and social treatment methods Killick K, Schaverien J (2003) Sanat, Psikoterapi ve Psikoz (Çev.: B Büyükkal).
İstanbul, Yelkovan Yayıncılık, 2003, s.14.
with a large number of patients. If these studies provide Kostakoğlu AE, Batur S, Tiryaki A (1999) Pozitif ve Negatif Sendrom Ölçeğinin
favorable data accumulation about the structured and easy- (PANSS) Türkçe uyarlamasının geçerlik ve güvenirliği. Türk Psikoloji Derg
to-use methods, we think that more schizophrenia patients 14: 23-32.
can have the chance to receive treatment with such methods Liberman RP (1986) Social and Independent Living Skills: Medication-
Management Module, Trainer’s Manuel. UCLA Department of Psychiatry,
in addition to drug therapies, as such training practices in this Los Angeles, CA.
field become more common in our country. Liberman RP (1987) Social and Independent Living Skills: Recreation For
Leisure Module, Trainer’s Manuel. UCLA Department of Psychiatry, Los
For more information about the art therapy methods used Angeles, CA.
in the study, the course of the sessions and description of Liberman RP (1988) Social and Independent Living Skills: Symptom
the practices through case examples, please refer to the study Management Module, Trainer’s Manuel. UCLA Department of Psychiatry,
Los Angeles, CA.
conducted by Sarandöl et al. in 2013 which applied the same
Meng P, Zheng R, Cai Z et al. (2005). Group intervention for schizophrenia in
methodology (Sarandöl et al. 2013). patient with art as medium. Acta Psychologica Sinica 37: 403-12.
Moriana JA, Alarcon E, Herruzo J (2006) In-home psychosocial skills training
for patients with schizophrenia. Psychiatr Serv 57: 260-2.
Özlü A, Yıldız M, Aker T (2009) Zarit bakıcı yük ölçeğinin şizofreni hasta
yakınlarında geçerlilik ve güvenilirlik çalışması. Arch Neuropsychiatry 46:
REFERENCES 38-42.
Patterson S (2007) Arts therapies for people with schizophrenia: an emerging
Addington D, Addington J, Maticka-Tyndale E et al. (1992) Reliability and evidence base. Evid Based Ment Health 10: 69-70.
validity of a depression rating scale for schizophrenics. Schizophr Res 6:
Richardson P, Jones K, Evans C et al. (2007) Exploratory RCT of art therapy as
201-8.
an adjunctive treatment in schizophrenia. J Ment Health 16: 483–91.
American Art Therapy Association AATA, 2017, Downloaded from https:// Sarandöl A, Akkaya C, Eracar N et al. (2013) The effects of art therapy carried
arttherapy.org/about-art-therapy/ on 20 May 2020. out with schizophrenic patients and their relatives, on symptoms, personal
Aydemir Ö, Danacı AE, Deveci A et al. (2000) Calgary Şizofrenide Depresyon and social skills. Anadolu Psikiyatri Derg 14: 333-9.
Ölçeği’nin Türkçe versiyonunun güvenilirliği ve geçerliliği. Arch Schooler NR (2006) Relapse prevention and recovery in the treatment of
Neuropsychiatry 37: 82-6. schizophrenia. J Clin Psychiatry 67: 19-23.
Beck AT (1961) An Inventory For Measuring Depression. Arch Gen Psychiatry Söğütlü L, Özen Ş, Varlık C et al. (2017) Toplum ruh sağlığı merkezinde şizofreni
4: 561-71. hastalarına ruhsal toplumsal beceri eğitimi uygulanması ve sonuçları.
Beck AT, Epstein N, Brown G et al. (1988) An inventory for measuring clinical Anadolu Psikiyatri Derg 18: 121-8.
anxiety: psychometric properties. J Consult Clin Psychol 56: 893-7. Tas C, Danaci AE, Cubukcuoglu Z et al. (2012) Impact of family involvement
Birchwood M, Smith J, Cochrane R et al. (1990) The Social Functioning Scale. on social cognition training in clinically stable out patients with
The development and validation of a new scale of social adjustment for schizophrenia—a randomized pilot study. Psychiatry Res 195: 32-8.
use in family intervention programmes with schizophrenic patients. Br J Ulusoy M (1993) Beck Anxiety Inventory: validity and reliability study.
Psychiatry 157: 853-9. Unpublished Specialization Thesis, Bakırköy Ruh ve Sinir Hastalıkları
Bora E, Gökçen S, Veznedaroğlu B (2008) Empathic abilities in people with Hastanesi, İstanbul.
schizophrenia. Psychiatry Res 160: 23-9. Üçok A, Atlı H, Çetinkaya Z et al. (2002) Şizofreni hastalarında bütüncül
Bora E (2009) Theory of mind in schizophrenia spectrum disorders. Türk yaklaşımlı grup tedavisinin yaşam kalitesine etkisi: bir yıllık uygulama
Psikiyatri Derg 20: 269-81. sonuçları. Arch Neuropsychiatry 39: 113-8.

114
Yıldız M (2001) Şizofrenide ruhsal toplumsal beceri eğitiminde içerik ve Yıldız M, Özaslan Z, İncedere A et al. (2019) Şizofrenide Ruhsal Toplumsal
etkinlikler. Klinik Psikiyatri 4: 119-23. Beceri Eğitimi ve Üstbiliş Eğitiminin Toplumsal ve Bilişsel İşlevsellik
Yıldız M, Yazıcı A, Ünal S et al. (2002) Şizofreninin ruhsal-toplumsal tedavisinde Üzerine Etkisi. Arch Neuropsychiatry 2019 56: 139−43.
sosyal beceri eğitimi - belirtilerle baş etme ve ilaç tedavisi yaklaşımının Zarit S, Reever K, Bach-Peterson J (1980) Relatives of the impaired elderly:
Türkiye’de çok merkezli bir uygulaması. Türk Psikiyatri Derg 13: 41-7. correlates of feeling of burden. Gerontologist 1980 20: 649-55.
Yıldız M, Tural Ü, Kurdoğlu S et al. (2003) Şizofreni rehabilitasyonunda aile
ve gönüllülerle yürütülen bir kulüp-ev denemesi. Türk Psikiyatri Derg 14:
281-8. Acknowledgement: We would like to thank Zeynep Aygül Şeker, Spec.
Yıldız M, Yüksel AG, Erol A (2005) Şizofrenide ruhsal ve toplumsal beceri Clinical Psychologist and Dr. Tugay Bilgen, Research Associate for their
eğitimi uygulaması grup eğitimi deneyimleri. Türkiye’de Psikiyatri 7: 25-32. support and great contributions to the group sessions in this study.
Yıldız M (2011) Spiritual Social Skills Training Instructor Handbook for
Schizophrenic Patients. Ankara, Turkey Social Psychiatry Publications.

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