Developing Effective Communication Skills in Counseling: A Focus on Schizophrenia and Depression

This study evaluates the effectiveness of Social Skills Training (SST) on improving social interactions and reducing psychological symptoms in individuals with schizophrenia by comparing pre-test and post-test scores of control and experimental groups. The quasi-experimental research, using a static group comparison design, involved five male post-hospitalized schizophrenia patients aged 19-40 in Nganjuk Regency. The experimental group received SST, while the control group did not. Results from paired sample t-tests indicated no significant change in the control group but showed significant improvement in the experimental group, with post-test scores significantly lower than pre-test scores (p < 0.05). Independent sample t-tests confirmed no significant difference in pre-test scores between groups, but post-test scores revealed significant differences, affirming SST's positive impact. The SST intervention, comprising sessions on communication, friendship, joint activities, handling difficult situations, expressing opinions, and family psychoeducation, significantly enhanced social skills and reduced negative responses. These findings highlight SST as an effective intervention for individuals with mental health issues, promoting better social interactions and reducing relapse rates, thereby supporting its integration into therapeutic practices.


INTRODUCTION
People with schizophrenia have a 10% lifetime risk of suicide.The disease first appears in early adolescence.The risk factors are socio-demographic characteristics, predisposing factors (genetic), and precipitating factors (family, cultural, and social environment).According to World Health Organization data, (2014) about 35 million suffer from depression, 60 million from bipolar, 21 million from schizophrenia, and 47.5 million from dementia.In Nigeria shows that schizophrenia occurs in all populations with prevalence in the range of 0.16 and 4.6 per 1000 and incidence rates in the range of 0.16 and 0.42 per 1000 population, the study revealed that on average 58.19% of the admitted patients were schizophrenic patients (Afolayan, Peter & Amazueba 2015).
The prevalence of mental disorders is approximately 1% in the United States, with a total of more than 2 million people (Nevid et al., 2005).People with schizophrenia in the world are estimated to be 0.6-1.9% a year (Crismon et al., 2008).The findings of the World Health Organization show that schizophrenia patients are almost the same in developed countries and developing cultures, an estimated about 25 million people in the world suffer from schizophrenia (Nevid et al., 2005).About 80% of the number of mental disorders get treatment in mental hospitals, the findings by Keliat et al., (2011) there are 25% of patients can be mentally healthy, 25% can do activities, 25% need help, and 25% have acute conditions.To treat schizophrenia patients is estimated to be around 30 billion US dollars each year, 75% of the expenditure in the United States proposed to do treatment on mental health (Nevid et al., 2005).
Schizophrenia disorder causes constraints on an individual's ability to think, solve problems, and disrupt social relationships (Oltmanns & Emmery, 2013).This leads to decreased function or inability of the patient to carry out their life activities, hampering productivity and interaction with others.A person who has schizophrenia looks different in terms of appearance, manner, or style of speech and behavior, making families and communities reject their existence.With the social separation of patients, they become increasingly socially unskilled or experience an inability to socialize when in society (Kimhy, et al, 2012).
Pharmacology and psychology are critical, aiming to provide therapy from various sides with positive results.From the pharmacological side, drugs are usually given routinely while psychosocial is a social skills approach.Teaching social skills to people with schizophrenia can help patients interact with others and succeed when in diverse interpersonal situations (Davidson, et al, 2006).In line with the results of research conducted by Andayani & Zulfiana (2021), shows that social skill training therapy can reduce the level of depression in adolescents which is accompanied by a change in behavior with increased confidence in interpersonal communication.In this case, social skill training can be used as a recommendation as a therapy for individuals experiencing mental health problems.A person with mental health problems can be minimized through regular care and treatment and can reduce costs incurred, such as with support to help each other ease the mental burden felt by patients and families, by changing the negative stigma of society about schizophrenia.This awareness is important because the success of patient care is influenced by social support McCrone et al., (2004).Supported by research showing that the support of surrounding people has an influence on the quality of life in patients with mental disorders by 47.4%, Fajrianthi (2013).
Social interaction is a relationship between one individual and another individual, between one group and another group, or between groups and individuals.Social interaction is the process of individuals being able to accept differences, in the sense of being able to adjust to everything in the community environment such as norms, and other people's behavior, where they are influenced by others.It can also be that other individuals adjust to the individual himself Gerungan, 2006).Social interaction occurs when individuals can communicate with each other, which is the initial process of forming social relationships, while communication is the delivery of information and provides predictions and responses related to the stimulus that has been conveyed.How many things can make a source of information when communication or interaction begins, the sources are physical characteristics and performance.Specific characteristics are something that have been carried by individuals since birth which include gender, age, and race.While performance is in the form of physical attractiveness, body shape, and how to dress Karp & Yoels (2010).
Social skills training is a behavior modification technique that is often carried out by researchers and has proven its success and contribution to the training.Subjects carry out a behavioral learning process to improve their ability to interact to be respected and socially accepted.Based on the techniques contained in the training, it is the basis for researchers to choose the concept model from Johnson's Behavioral System Model as the basis for implementing social skills training therapy for post-hospitalization schizophrenia patients.(Renidayati, 2008) created a social skills training module to be applied to individuals experiencing social isolation by referring to the 4 stages described by Stuart & Laraia (2005), namely by training individuals' ability to communicate, training to behave well towards others and when encountering difficult situations, through modeling, re-practicing, providing feedback and transfer training.The focus of emphasis of Johnson's model according to Leddy & Pepper (1993, in Tomey & Aligood, 2006) is, the individual as a behavioral component, the component is seen from actions and behaviors that are consistent and controlled by biological factors, psychological factors, and sociological factors.The system consists of seven interaction results of behavioral forms that result in specific functions for all components as a whole.
Schizophrenia patients are one of the patients who have social interaction problems, social skills training itself is given to individuals who are less able to interact.(Lee, Yeh, & Lo, 2011) conducted a study showing that Social skills training intervention can significantly improve communication skills in schizophrenia patients, improve the patient's social function, and improve the ability to solve problems.Patients with schizophrenia and their families experience several complaints including decreased communication function, and decreased ability to socialize.(Michelson, et al, 1985) suggested that SST is made to improve communication and social skills in individuals.Social skills training is a form of skill or ability to convey praise, being able to express opinions that individuals think are not appropriate, refute the wishes of other individuals, exchange knowledge, ask for what is already theirs, give advice to others, solve problems, establish cooperation with people of the opposite sex, establish relationships with others, regardless of social status Michelson, et al (1985).This training is applied based on considerations that will be changed by the individual concerned (Bulkeley and Cramer, 1990).The coach's job is not to make statements or reflect, but rather to provide a single reinforcement, and to actively teach the desired behavior.The trainer is not intervening as in psychotherapy, but rather training.The focus of skills training is on teaching specific behaviors, not values, attitudes, or insights, and is a behavioral approach designed to develop visible actions.The definition of Social skills training that has been put forward can be summarized as a learning process to improve the ability to interact with others in a social context that is socially acceptable and valued.It involves the ability to initiate and maintain positive and mutually beneficial interactions.

METHOD
This study uses the quasi-experiment research method, using The static group comparison design, namely there is a control group and an experimental group.In this design, only the experimental group is given treatment, and then the two groups are given a post-test then the results are compared (Creswell, 2010).This method is used to obtain more accurate results in knowing the effectiveness of Social skills training in improving social interaction in posthospitalization schizophrenia patients, namely by comparing the results between groups.

Research Subject
The research subjects were 5 male post-hospitalized schizophrenia patients in Nganjuk Regency with an age range of 19-40 years.The sampling technique used purposive sampling, with the criteria of subjects with low scores in social interaction, namely with consideration in the hope of obtaining information relevant to the researcher's objectives (Darmadi, 2013).

Instrument And Data Collection
The research instrument used a social skill scale measuring instrument made by the researcher based on aspects of social interaction, namely: (a) communication, (b) attitude, (c) group behavior, and (d) social contact, which consists of 12 statement items.There are 4 scales, namely: Strongly Disagree rated 1, Disagree rated 2, Sometimes rated 3, Agree rated 4 Strongly Agree rated 5.The procedure in making the scale includes providing information to related parties about ethics such as the right to withdraw, confidentiality, etc. is also taken into account.The validation of the social skills scale is divided into three stages, namely) the item writing stage and content validation.II) Factor analysis, III) Reliability and validity testing which then the scale was tested on subjects using the criteria of the subjects in this study.based on the results of the trial, the reliability value α = 0.829 was obtained.

Implementation of Intervention in Patients
In this intervention, a social skills training module will be created, this module has seven sessions, tailored to the conditions or problems of clients with schizophrenia, by referring to the stages of social skills training, namely training skills for communication, establishing friendships, and dealing with difficult situations, using the method of modeling, role-playing, providing feedback regarding how much contribution during training, by looking after the client demonstrates the task, transferring training, namely practicing skills obtained from training/intervention into daily activities.The intervention given to the family is the provision of family counseling.Psychoeducation provided to the surrounding environment is psychoeducation on understanding schizophrenia for approximately 60-120 minutes by bringing in models of former schizophrenia sufferers.

Data Collection Procedures
The data collection used by researchers includes: (a) Observation.Observation here is carried out by researchers during the research process both during the pre-test and post-test of participants, which aims to reveal and predict the basis for the emergence of behavior.(b) Interview.Interviews here are conducted by researchers to patients and also the surrounding environment who are considered to be able to provide information related to patients.The information obtained is then used as the basis for determining the prognosis of the intervention to be given to the patient so that the intervention can be carried out appropriately, d) measurement scale.The measurement scale here is used as a tool for screening and also as a reference for determining the pre-test and post-test values of the study.So that researchers can find out the psychological problems experienced by patients following the context of this study.

Data Analysis
Data analysis used the paired sample t-test technique.This technique is used to test the significance of the difference between two means derived from two distributions (Winarsunu, 2002).

RESULTS AND DISCUSSION
In Table 1, it is known that there are 5 control groups observed, obtained a pre-test average value of 26.40 with a standard deviation of 4.51, then obtained a post-test average of 26.60 with a standard deviation of 3.51 so that there is an increase in the average value of 0.20.The paired sample t-test results show a significance value of more than 0.05 (sig> 0.05) so it is stated that there is no significant change in the control group.In the experimental group of 5 people observed, the pre-test average value was 27.60 with a standard deviation of 2.70, then the post-test average was 14.20 with a standard deviation of 3.77 so that there was a decrease in the average value of 13.40.The paired sample t-test results show a significance value of less than 0.05 (sig <0.05) so it is stated that there is a significant change in the experimental group.

Unpaired Sample T-test
The unpaired sample t-test is a test to determine the difference between the control group and the experimental group conducted on the pre-test and post-test scores.The test was conducted using an independent sample t-test with the following results.The pre-test value in the control group obtained an average of 26.40 with a standard deviation of 4.51 and the experimental group obtained an average of 27.60 with a standard deviation of 2.70 so that there was a difference in the average value of 1.20.The results of the independent sample t-test show a significance value of more than 0.05 (sig> 0.05) so it is stated that there is no significant difference in the pre-test value.The post-test value in the control group obtained an average of 26.60 with a standard deviation of 3.51 and the experimental group obtained an average of 14.20 with a standard deviation of 3.77 so there was a difference in the average value of 12.40.The results of the independent sample t-test show a significance value of less than 0.05 (sig <0.05) so it is stated that there is a significant difference in the post-test value.The intervention used was social skills training.Social skills training (SST) is one of the interventions with behavior modification techniques based on the principles of role-play, practice, and feedback to improve the client's ability to solve problems in clients with depression, schizophrenia, clients with behavioral disorders with difficulty interacting, experiencing social phobia and clients who experience anxiety to enable the person to interact by providing positive responses to the environment and reducing negative responses that may be present in him (Stuart, 2009).The results of this study indicate that the paired sample t-test results in the control group show a significance value of more than 0.05 (sig> 0.05) so the value is stated that there is no significant change in the control group.The results of the independent sample t-test show a significance value of more than 0.05 (sig> 0.05) so it is stated that there is no significant difference in the pre-test value.The paired sample t-test results in the experimental group showed a significance value of less than 0.05 (sig < 0.05) so it was stated that there was a significant change in the experimental group.The results of the independent sample t-test show a significance value of less than 0.05 (sig < 0.05) so it is stated that there is a significant difference in the post-test value.
Social skills training is based on the belief that skills can be learned therefore it can be learned that someone who does not have it (Stuart & Laraia, 2008).The definition of Social skills training that has been stated can be concluded as a process of teaching a person to improve the ability to interact with others in a social context that is socially acceptable and appreciated.This involves the ability to initiate and maintain positive and mutually beneficial interactions.According to Eikens (2000), Social skills training aims to; 1) Increase a person's ability to express what is needed and wanted; 2) to reject and convey the existence of a problem; 3) to respond during social interaction; 4) Able to initiate interactions; 5) Able to maintain interactions that have been built.This intervention will develop a social skills training module for clients with schizophrenia by referring to the empathy stages of social skills training proposed by Stuart (2009); namely training clients' ability to communicate, establish friendships and deal with difficult situations, using the methods of modeling, role play, performance feedback, namely the stage of providing feedback.Feedback is given immediately after the client tries to act out how well the exercise is running, transfer training, is the stage of transferring the skills acquired by the client into daily practice.The social skills training module has 7 sessions, the intervention is carried out at the subject's home based on the contract agreed upon by the subject and the subject's family.The following are the sessions in the implementation of the intervention: Session 1. Opening, namely the researcher states the purpose and implementation of social skills training, agrees with the subject to keep following during the intervention activities, and makes it comfortable so that the subject is motivated to carry out during the intervention process.This session aims to provide an understanding of the subject regarding the intervention process to be carried out.Practitioners provide an overview of the subject's problem self, based on the results of the assessment and an overview of how the subject deals with each existing problem.Practitioners provide an understanding of how the subject can communicate with family members when facing problems, train the subject to foster an attitude of openness with the family and be able to express what he feels and train the subject to interact with other people and the surrounding environment.In addition, the practitioner also provides support to the subject, that the subject's family, especially the mother, really loves the subject, this is given with the aim that the subject can foster a sense of trust in members to be able to establish interaction and openness with family members.Session 2. The therapist trains the client's ability to communicate, namely explaining to the subject about using appropriate body language when dealing with other people as well as, saying greetings, speaking well, having the courage to answer questions, and asking for clarification.Session 3 Training the client's ability to establish friendships, namely training the subject's ability to give praise, ask for and provide help to others, including practicing participating in activities with peers, with older people, younger people, and with the opposite sex.Session 4 Train the client's ability to engage in joint activities with others, namely the therapist invites the subject to participate in social community activities such as; inviting cooperation with the community in the neighborhood where the subject lives.
Session 5 Train the client's ability to deal with difficult situations, namely explaining to the subject about ways to deal with difficult situations by giving positive responses such as, when the subject receives criticism, accepts rejection, and apologizes, Session 6 Train the ability to express opinions, build confidence in the subject in conveying an opinion and, explain to the subject about how good it is to convey an opinion with a positive delivery so that it can be accepted by others, Session 7, namely Providing psychoeducation to the family In conducting this intervention, practitioners emphasize psychoeducation given to the family because optimal family support and participation can minimize relapse in the subject.In this session, practitioners gathered all family members and had previously explained the purpose of psychoeducation to the family, this intervention began by building rapport with the family for approximately 60-120 minutes, discussing with the family about the subject's condition.
Then the researcher gave an explanation to family members regarding the current disorder experienced by the subject and explained what activities were given to the subject when at home, besides how the family provided support and attention to the subject to reduce relapse.In addition, the practitioner also explained to the family to invite the subject to exercise to reduce his anxiety and teach him to be open with all family members.By giving praise or attention when the subject succeeds in doing positive things and helping the subject foster his sense of self by always communicating with the subject.Conducting routine controls according to the schedule set at the hospital and supervising the subject to take medication regularly.Practitioners provide an understanding related to schizophrenia, the symptoms of schizophrenia, and how to prevent relapse in the subject.

Implications for Counseling and Guidance
The findings of the study reveal significant insights into the effectiveness of Social Skills Training (SST) as an intervention for enhancing social interaction and reducing psychological symptoms in individuals with mental health challenges, such as schizophrenia.These results have several important implications for counseling and guidance practices.Firstly, the significant improvement observed in the experimental group highlights the importance of structured interventions like SST in counseling.Practitioners should incorporate SST modules into their therapeutic practices, focusing on key areas such as communication skills, building friendships, participating in social activities, and handling difficult situations.Additionally, the study underscores the necessity of tailoring intervention programs to meet individual client needs.Counselors should assess the specific social skill deficits and psychological needs of their clients to customize SST modules effectively.This personalized approach can enhance the overall efficacy of the intervention.
Furthermore, the psychoeducation component of the SST module, which involves educating family members about the client's condition and how to provide support, is crucial.Counselors should actively engage family members in the therapeutic process, providing them with the necessary knowledge and skills to support the client's social and emotional development.This collaborative approach can significantly reduce relapse rates and promote sustained improvement.Psychoeducation should be a fundamental aspect of counseling interventions.Educating clients and their families about the nature of the psychological condition, treatment methods, and ways to support the client's progress can empower them and foster a supportive environment conducive to recovery.
Moreover, the initial session of SST, which focuses on building trust and rapport with the client, is essential for the success of the intervention.Counselors should prioritize establishing a strong therapeutic alliance, ensuring that clients feel comfortable and motivated to engage in the intervention process.Regular assessment and feedback are crucial components of effective counseling.Counselors should continuously monitor clients' progress through standardized measures and provide immediate feedback to help clients recognize their improvements and areas needing further development.The results also indicate the importance of encouraging clients to participate in positive social interactions.Counselors should facilitate opportunities for clients to engage in community activities, develop new social connections, and practice newly acquired social skills in real-life settings.
Teaching clients how to cope with difficult situations, such as receiving criticism or dealing with rejection, is vital.Counselors should equip clients with effective coping strategies to manage stress and negative emotions, enhancing their resilience and social competence.The study supports a holistic approach to mental health, integrating behavioral, cognitive, and social aspects of treatment.Counselors should adopt a comprehensive approach that addresses multiple facets of the client's life, promoting overall well-being and social functioning.Finally, sustained support and follow-ups are essential for maintaining the gains achieved through SST.Counselors should schedule regular follow-up sessions to reinforce learned skills, address any emerging challenges, and provide ongoing encouragement and support to clients and their families.By integrating these implications into counseling and guidance practices, practitioners can enhance the effectiveness of their interventions, supporting clients in developing essential social skills, improving their quality of life, and fostering long-term psychological well-being.

CONCLUSION
The study aimed to examine the impact of social skills training (SST) on individuals by comparing pre-test and post-test scores within control and experimental groups using paired sample t-tests and independent sample t-tests.The paired sample t-test results indicated no significant change in the control group but showed a significant reduction in scores for the experimental group, suggesting substantial improvement due to SST.The independent sample t-test results confirmed no significant difference in pre-test scores between the groups, but a significant difference in post-test scores, affirming the positive effect of SST on the experimental group.The SST intervention involved sessions focusing on communication, establishing friendships, engaging in activities, dealing with difficult situations, expressing opinions, and providing psychoeducation to families.These sessions led to enhanced social skills and reduced negative responses among participants in the experimental group.The findings suggest that SST is a valuable tool for clients with conditions such as schizophrenia, depression, social phobia, and anxiety, promoting better social interactions and reducing relapse rates.Overall, the study provides evidence that SST is an effective intervention for improving social competence and reducing negative behaviors in clients, with significant improvements observed in those who underwent the intervention.
Paired Sample T-testPaired sample t-test is a test to determine the difference between pre-test and post-test scores in each control group and experimental group.The test was conducted using paired sample t-test with the following results.