Introducción.

La evaluación de habilidades sociales para el trabajo en esquizofrenia de Tsang y Pearson (EHSTE) resulta un método especialmente valioso en virtud de que, a diferencia de la mayoría de medidas generales de habilidades sociales disponibles a la fecha, ésta se dirige a evaluar específicamente los problemas y necesidades de las personas con esquizofrenia para conseguir y mantener un trabajo; y porque las otras herramientas de evaluación del constructo especialmente diseñadas para esta población son más bien listas de chequeo. La EHSTE consta de dos partes: 1) Una escala de auto administración (AA) que evalúa la percepción subjetiva de los pacientes acerca de su competencia en habilidades sociales relacionadas con la obtención y el mantenimiento de un trabajo; y 2) Un ejercicio simple de juego de roles para evaluación por expertos (EE), en donde se observa la ejecución social de los pacientes en la simulación de dos situaciones laborales: solicitar trabajo en una entrevista y pedir autorización a un supervisor para ausentarse en un día cotidiano de trabajo. El objetivo del presente estudio fue traducir al español y evaluar la confiabilidad y validez de las formas de AA y EE que integran la EHSTE, en pacientes mexicanos con esquizofrenia.

Método.

Con base en un muestreo no intencional de pacientes atendidos en los servicios de consulta externa y hospitalización del Centro de Atención Integral en Salud Mental del Instituto Jalisciense de Salud Mental, se conformó una muestra de adultos de ambos sexos con diagnóstico de esquizofrenia en cualquiera de sus tipos. El diagnóstico fue confirmado mediante la entrevista estructurada SCAN y se completó la AA y EE en el total de la muestra. Adicionalmente, un psiquiatra registró su funcionamiento global mediante la escala propuesta por la Asociación Psiquiátrica Norteamericana (EEAG) así como otras variables sociodemográficas y clínicas relevantes para el estudio. A los quince días, un sub grupo participó en una segunda aplicación de ambas formas de evaluación de la EHSTE.

Resultados.

Participó un total de 54 pacientes con esquizofrenia. Los coeficientes Alpha de Cronbach fueron, para la AA=0.69 y para la EE=0.85. Un total de 36 pacientes completaron las evaluaciones inicial y a 15 días, y las correlaciones entre ellas fueron: para AA=0.66, y para EE=0.73, p≤.01. En el total de la muestra, las puntuaciones en la EEAG y EE se correlacionaron alta, positiva y significativamente (r = 0.71, p ≤.01). Empero, la relación entre EEAG y AA no fue estadísticamente significativa. Asimismo, la puntuación EE, y no la de AA, fue clínica y estadísticamente superior en los pacientes atendidos en consulta externa vs. hospitalización (12.9 ± 2.5 vs. 10.72 ± 3.4; t=-2.77, gl = 52, p = .008); con mejor funcionamiento psicosocial (59.79 ± 8.5 vs. 52.12 ± 8.5; t = 2.97, gl = 52, p = .004), y entre aquellos que tenían experiencia laboral (12.76 ± 2.55 vs. 8.91 ± 3.53; t = 4.11, gl = 51, p≤.0001). No se registraron diferencias por género.

Conclusiones.

Se aporta evidencia de consistencia interna, estabilidad temporal y validez de constructo de la evaluación de habilidades sociales para el trabajo por expertos y mediante la técnica de juego de roles, en pacientes mexicanos con esquizofrenia. Se recomienda que la evaluación de este constructo en pacientes de habla hispana y con baja escolaridad se haga con base en este método, pues los formatos de auto aplicación pueden ser una herramienta de cuestionable validez y confiabilidad en esta población. Sin embargo, serán necesarios futuros estudios que permitan la generalización de los resultados en el entendido de que existen diferencias culturales importantes en ésta como en muchas otras variables de funcionamiento humano.

Introduction.

Only 20 to 30% of psychiatric disorders patients have a full-time competitive job. These figures might dramatically drop to 15% for those with more severe and persistent mental disorders, like schizophrenia, and could be obviously much lower in patients from developing countries.

Lack of social competence and social skills necessary in the workplace have been suggested as an individual variable that explain the frequent difficulty in acquiring and maintaining a job among people with schizophrenia. Therefore, social skills' training has been widely used as an effective treatment modality to counteract those deficits.

In order to develop cultural sensitive treatments, it is generally accepted that it is necessary to have valid and reliable methods to evaluate this construct in every particular population.

Tsang and Pearson (2000) proposed a work-related social skills evaluation specifically designed for people with schizophrenia. This measure is composed of two parts: 1. A self-administered scale that evaluates subjective perception about social competence related to obtaining and maintaining a job. In this instance, patients rate a ten-item scale according to the degree of difficulty they experience in handling the situation. 2. A simple role playing exercise in which an expert evaluates the patient's work-related social skills by the simulation of two situations: participating in a job interview, and requesting one day of leave at short notice from a supervisor. Here, the kinds of behaviour rated include basic social survival skills, basic social skills related to voice quality and nonverbal communication, and overall performance. The expert evaluator uses a five point scale in which 4 indicates a normal performance and 0 a poor one.

This kind of evaluation offers advantages compared to general social skills measures that were not designed to evaluate people with persistent and severe mental disorders, and specifically over the ones that consist merely in check lists.

The aim of the present study was to translate into Spanish and to evaluate the reliability and validity of Tsang and Pearson's both self-administered scale (SA) and expert evaluation (EE) of work-related social skills among Mexican patients with schizophrenia.

Method.

A non-random sample of male and female Mexican adults with a confirmed diagnosis of schizophrenia by the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), completed SA and EE evaluations. Additionally, a psychiatrist recorded their global functioning based on the evaluation proposed by American Psychiatric Association (GAF), and all relevant socio-demographic and clinical variables (gender, age, educational level, previous work experience, and type of service required, between ambulatory and hospitalized patients). Fifteen days later, a sub-sample participated in a second evaluation with both work-related social skills measures. Cronbach’s alphas were calculated for SA and EE measures to obtain internal consistencies. Pearson's correlations were performed to determine the relationship between these measures and first and fifteen day after applications, to have the data of split-half reliability and short temporally stability, respectively.

Then, convergent validity was evaluated with Pearson correlations between GAF scores and both SA and EE work-related social skills measures. Finally, the expected relationship between global functioning and type of mental health service employed (ambulatory service vs. hospitalization) was evaluated comparing both patient groups with independent samples t-Student test. EE and SA scores between these groups were then compared using another t-test. In all cases, predetermined alpha value was 95%.

Results.

A total of 54 schizophrenia patients was recruited; 64.8% were males (n=35) and 35.2% (n=19) females. Overall mean age was 36.6 ± 9 years old (range = 19-57). Years of formal education mean was 7.6 ± 3.8 (range = 1-17); and 77.8% reported some kind of previous work experience (non-competitive job; n = 42). Practically half of them were attending external consultation services (53.7% ambulatory patients, n = 29) and the rest of them were hospitalized (theoretically with more severe disorders).

Reliability data. Cronbach´s alphas coefficients were SA=0.69, EE=0.85. A sub-sample of 36 patients completed initial and fifteen day work-related social skills evaluations. Correlations between them were SA=0.66 and EE=0.73, p≤.01.

Validity data. For all the sample, high, positive and significant correlations between GAF and EE was obtained (r= 0.71, p≤ .01). No statistical relationship among GAF and AA was observed. EE total scores, but not SA ones, were clinically and statistically higher among outpatients in contrast to those who were hospitalized (12.9 ± 2.5 vs. 10.72 ± 3.4; t=-2.77, gl=52, p=.008). In congruence, outpatients had a better global functioning (59.79 ± 8.5 vs. 52.12 ± 8.5; t=2.97, gl=52, p=.004). Similarly, higher EE scores were obtained by patients with previous job experience (12.76 ± 2.55 vs. 8.91 ± 3.53; t=4.11, gl=51, p≤.0001). No gender differences were observed.

Conclusions.

Evidence of internal consistency, temporal stability and construct validity of EE format to measure work-related social skills among Mexican patients with schizophrenia were documented. Still, the self-administered scale did not show enough reliability coefficients nor validity indicators. This is congruent with data offered for the original version in English: Expert evaluation Cronbach’s alphas were higher than the self-reported ones (.96 vs .80, respectively). However, for both SA and EE evaluations, the original English versions internal consistencies were higher than the Spanish ones evaluated in the present study. This could be explained by years of education and work status disparities among the samples.

The expert evaluation by role playing showed a better short-temporal stability than the self-administered scale. Additionally, the EE scores, but not the SA ones, correlated in a high, positive and statistical fashion with the general functioning of the patients, and were higher in ambulatory than in hospitalized patients. Similarly, the original English EE, but not the SA evaluation, demonstrated better validity indicators by comparing people with and without schizophrenia.

These data suggest that the evaluation of this construct among Mexican patients with a low educational level has to be performed by an expert using role playing exercises, instead of self-administered scales. Further studies are necessary in order to generalize the use of these measures among other populations.