In Reply:It is notable that Dr. Tsang, using social skills training in a Chinese culture, has also found training in problem solving to be an important element in teaching his clients a variety of social and vocational skills. Such cross-cultural replications provide another type of validation to evidence-based treatments for persons with serious and persistent mental disorders.
There are three points that can be made to further clarify—beyond the evident efficacy of the procedure—the rationale and utility of teaching problem-solving skills to persons with schizophrenia. First, many persons with schizophrenia have cognitive deficits presumably resulting from abnormal neural circuits between the thalamus, temporal lobe, and prefrontal cortex. These deficits may hinder their ability to anticipate, cope with, and flexibly solve problems of everyday life. In fact, the relationship between neurocognitive executive functions and social and vocational functioning has been highlighted in numerous studies over the past decade (1,2).
Moreover, social problem solving has been shown to be deficient in persons with schizophrenia compared with persons with no mental disorders (3). If neurocognitive impairments contribute to the disability experienced by persons with schizophrenia, then these persons are likely to benefit if they can be equipped with a "prosthesis" to lean on for dealing with the everyday challenges and stressors of life. From this point of view, teaching individuals with schizophrenia how to use systematic, stepwise problem solving may help mitigate or overcome their biologically based deficits.
Second, the plasticity of the brain has been documented by both basic studies with animal models and demonstrations that cognitive remediation, or "training the brain," is feasible (4). Research on social skills training has shown repeatedly that persons with schizophrenia have the capacity to learn new skills if structured behavior therapy techniques and procedural learning are used to overcome neurocognitive impairments. Thus there is every reason to believe that patients with schizophrenia can acquire problem-solving skills to enhance their community reintegration and independence. The flexibility and capacity of the brain to compensate for neurodevelopmental abnormalities, when paired with a highly structured and systematic training program, may lead to a more optimistic prognosis for persons with schizophrenia.
Third, the final step in problem solving involves encouragement and reinforcement of individuals for implementing one or more alternative solutions for attaining their goals in real-life situations. Thus, homework assignments are often where the "rubber hits the road" in determining the success of the problem-solving procedure. A considerable amount of research has documented the value of using assignments in a person's natural environment to improve therapeutic outcome (5). Some of the benefit of assignments may come from the additional practice that is gained in real-life settings, some from increased motivation generated by the assignments, and some from enhanced generalization and the experiences of success that accompany generalization.