Evaluation of Family Psychoeducation Program for Caregivers of Schizophrenia Patients in

Singapore.

Ng, Vincent C.K. & Low, M.H

Introduction

The Family Psychoeducation Programme (FPP) is a structured, time-limited, educational

programme that provides information, support and specific coping skills to families of schizophrenic
patients. Such a programme is introduced to help families cope with the demands of caregiving
responsibilities as the treatment approach for schizophrenic patients, with the goal of reintegrating
patients back to the community. It forms a crucial aspect of a community-based rehabilitation strategy to
prepare families to take on the caregiving role. Generally, psychiatric patients in Singapore are admitted
to a mental hospital for treatment lasting appropriately between 1 to 4 weeks, with follow-up in community
care and rehabilitation.

With the transition in the emphasis of care, family caregivers of these patients are challenged with
the responsibility of caring for the mentally ill (Spaniol et al, 1987). Hall (1999) reported as many as 75%
of persons discharged from psychiatric hospitals return home to live with their families and as many as
90% of persons with severe mental illnesses stay in regular contact with their families as frequent as
every day. These findings showed that severe mental illness have far reaching consequences for both
the patients and their families (Pollio et al, 2001; Hatfield & Lefley, 1987; Tessler et al, 1987). With this
trend, responsibilities of caregiving have been transferred from institutions to families. (Stueve et al, 1997)

Therefore, the roles that families play in the support and care of their relatives with mental illness
have gained increased attention in the past two decades. Recognising the family as an asset in the care
of the patients has brought to the attention of mental health providers the need to support family
caregivers in this demanding task, as it is also recognised that the personal cost to the family in providing
support and care can be high; where burn-out is likely if providers do not provide appropriate support and
information (Hatfield, 1997; Hugen, 1993). As a result, new forms of supportive family intervention have
been developed over the past two decades.

These programs, often labelled as psychoeducation, speaks not only of providing help, in which
varying emphases are placed on problem-solving, communication training, information-giving, and
behavioral management but also of establishing alliance with families and working with them on the basis
of equity and partnership (Ibid, 1993). In fact, there are in general 5 models of psychoeducational
treatment that vary according to length of treatment, what family members are presented; where the
treatment is provided, and the emphasis. Nevertheless, regardless of the models, these approaches aim
to provide information, skills, and support to family caregivers (Simon et al, 1991). These interventions
have been useful in reducing relapses amongst the patients, and responding more appropriately to the
needs of families (Anderson, et al, 1980; Berkowitz et al, 1984; Falloon et al, 1984; Goldstein, 1983,
1994).
Literature Review

There are a number of outcome studies examining the effectiveness of family psychoeducation
as a treatment method for schizophrenia. Such studies have received repeated empirical support over
the past decade. In fact, Hogarty et al (1986) reported the such intervention was able to reduced family
caregivers’ level of expressed emotion, resulting in delayed relapses amongst patients in a one-year
controlled study on relapse and expressed emotions. It was reported that the overall relapse rate was
approximately 16%, and there were no relapses in the experimental group during the first 3 years of the
project. This study suggested that that long-term application is effective in helping patients and their
family caregivers

Other controlled studies by Falloon and colleagues (Falloon, et al, 1985; Falloon & Pederson,
1985) found that clients and their families in family psychoeducational treatment programs can acquire

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on1
Psychotherapy 12-15 March 2003, Suntec City, Singapore
and obtain information about schizophrenia more readily than can clients and families involved in
individual treatments. Further, these families reported less disruption of activities and that it also reduced
negative affective climate of the family by increasing parent’s ability to use non-emotional, constructive
ways of talking to the client during an emotionally charged discussion. (Doane et al, 1986).

Zhang et al (1999) also reported similar findings in a research in Mainland China. The annual
relapse rate in the experimental group was much lower than that in the control group (17.6% and 23.2%,
p < 0.01) and the rate of regular work in the experimental group was higher than that in the control group
(37.5% and 30.0%, p < 0.05). At the end of the second year, the relatives in the experimental group had
less care burden, better mental and physical health status, and more knowledge of caring for
schizophrenics than those in the control group. However, there was no mention about what contents of
the psychoeducation were helpful to the clients.

Despite the well-established knowledge that long-term psychoeducational program is effective,

mental health clinicians tend to implement short-term versions of these models as they are constrained by
scarce resources. There are many studies on the efficacy of family psychoeducation in the field but there
are limited studies locally. Bentelspacher (1997) and Goh (1993)’s study on family psychoeducation in
Singapore had indicated that such a programme was found to be useful by the family caregivers of
schizophrenic patients. However, all these studies focused mainly on the overall effects of the
programme on the participants. Nevertheless, there are no studies that examine the relevance of the
content of the programme when the program is applied to our local clientele as they assumed the
relevance of the contents. In addition, there are limited studies that examine specifically on brief family
psychoeducation. Currently there are no local studies looking into the content relevance of a specific
family psychoeducation programme.

Methodology

To assist the family to better cope with their responsibilities within the constraint of resources, the
Medical Social Work Department in the Institute of Mental Health (IMH) implemented a brief family
psychoeducation programme. The aims of the programme are as follows:
1. The passing on of information with the goals of giving a rationale for treatment, including medication.
2. Reducing relatives’ guilt and / or blame particularly about aetiology.
3. Encouraging realistic expectations regarding prognosis.
4. Giving practical advice about management including ways of reducing expressed emotions.

The target clientele were family caregivers of schizophrenia patients from the acute psychiatric
wards in the institute. Family caregivers were referred to this programme by the psychiatrist from the
respective wards prior to the patient’s discharge. These family caregivers were invited to attend one-
morning (3-hour) psychoeducation workshop.

The workshop utilizes the outline and materials designed after psychoeducation programmes
developed by Anderson, et al (1986); Berkowitz et al (1984); Bernheim and Lehman (1985); Falloon et al
(1984); Goldstein (1983); and Winterstein (1988). This included information on schizophrenia (etiology,
course of illness, and symtomatology etc), its management (medication, treatment, and rehabilitation etc),
and coping skills for the family (positive family contribution, social support, and community resources etc).

The FPP was conducted by trained Medical Social Workers from the institute, with varying level of
experience ranging from 1 to 12 years. The format of the workshop was primarily didactic in nature,
accented with handouts, and visual presentations. This was followed by a short discussion time after the
end of each presentation, facilitated by the presenter.

The total sample size of 80 family caregivers was surveyed, comprising 40 from the treatment
group and 40 from the comparison group. A systematic random sampling method is used, whereby the
family caregivers of every 3rd patient admitted for treatment of schizophrenia, who had declined to be
referred to the FPP, were sampled into the comparison group. As for the family caregivers of
schizophrenic patients who agreed to participate in the FPP, every 3 rd referral was sampled into the

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on2
Psychotherapy 12-15 March 2003, Suntec City, Singapore
treatment group, based on similar principle of systematic random sampling. Prior to assigning them to the
experimental group, the purpose of the study was explained to them and consent from them was
obtained.

Research hypotheses:

In order to study the efficacy of the Family Psychoeducation Programme (FPP) in attaining the
aims set up by the study, the following research hypotheses were tested, namely:

1. Family caregivers who did not go through a structured psycho-education programme have less
knowledge in the understanding of schizophrenia and its management; and

2. Knowledge about the managing the patient’s illness will enhance the family’s confidence in managing
the patient after his/her discharge.

Instruments:

The efficacy of the FPP was measured in terms of the knowledge enhancement as well as the
general acceptability of the programme, as indicative from the level of client satisfaction after having
attended the FPP. Knowledge enhancement was measured by an instrument developed in-house,
consisting of 10 multiple-choice questions pertaining to symptomatology and management techniques of
Schizophrenia. Each of the questions had only one correct answer and the maximum attainable score is
10. The instrument was administered at 2 points: 1 week before the FPP workshop, and immediately
after the workshop. Another group of respondents, consisting 40 family caregivers who declined to attend
the FPP workshop, for various reasons; were also administered with the instrument, thus forming a
comparison group.

An additional instrument was administered to the treatment group participants. This

instrument aims to measure the level of satisfaction of the participants after they had completed the FPP.
This instrument is adapted from Attkisson(1985)’s Client Satisfaction Questionnaire (CSQ-8), which
implicitly implies that the greater the level of satisfaction, the greater the level of relevance of the FPP.

Results

A total of 40 respondents who participated in the FPP were sampled in this study. They consisted
of family caregivers of patients diagnosed with schizophrenia, of which 85% were Chinese, 10% Malays,
and 5% from other ethnic groups. In terms of gender distribution, 70% of the patients were males. The
mean age of the patients was 34 (n=40, s.d 9.45), and they have an illness history of 7.70 years (n=40,
s.d 4.92). In terms of marital status, 85% of the patients were single and the rest married. Distribution
across patients' religion were fairly even, with 25% Buddhists, 20% Christians, Taoists, and Free-thinkers
respectively, 10% Muslim and 5% Hindus.

It was interesting to note that 75% of the patients managed to complete at least secondary
education, despite their illness (35% completed secondary and 40% completed tertiary). Another 15%
had received vocational training. Only 10% had primary education or less. This suggested that most of
the patients was first diagnosed with the illness in their 20s, after completing their secondary education.
Such a profile is consistent with those found in major literature on Schizophrenia. A majority of the
patients received care by their parents (70%), while the rest, either by their spouse or siblings (both 15%).
Thus, this illuminates the paramount need for family support programmes such as the FPP, so that
schizophrenic patients living in the community can continue to receive effective care and support.

To find out the difference in the level of knowledge between the control and treatment group, as
well as before and after intervention, for the treatment group, bivariate analyses were carried out. The

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on3
Psychotherapy 12-15 March 2003, Suntec City, Singapore
 results between the pretest and the posttest, and between the control and treatment groups, were
compared in Table 1 and 2 respectively:

Table 1: Pretest and Posttest Results on Knowledge about Schizophrenia

N M SD t

Pretest 40 6.35 1.61 9.303*

Posttest 40 7.80 1.09

*p<.05 (paired sample t test)

Table 2: Comparison Between Control Group and Treatment Group (Pretest) on Knowledge about
Schizophrenia
N M SD t

Control 40 4.30 .99 6.570*

Treatment 40 6.35 1.61

(Pretest)
*p<.05 (paired sample t test)

The results suggested that the respondents had acquired better knowledge about Schizophrenia,
after having participated in the FPP workshop (t[39]= 9.303, p<0.05; 2-tailed). In addition, family members
who declined to attend the FPP generally had less knowledge about the illness and its management, as
indicated by their lower mean scores, compared to their counterparts’ pretest baseline score (t[39]= 6.570,
p<0.05; 2 tailed).

Satisfaction with the FPP was assessed using a 15-item questionaire with a 4-point Likert-type
scale (1 = strongly disagree, 4 = strongly agree), modelled closely to the Client Satisfaction Questionaire
developed by Attkisson (1985). Additional items were included to find out the usefulness of specific
components in the program’s content, such as etiology of the illness, symtomatology, coping strategies,
treatment methods, and community resources. In addition, respondents’ preference for more sessions
and their level of confidence in managing the patient at home after participating in the program were also
included.

The participants were generally very satisfied with the FPP workshop (M=2.95, s.d .50), where
90% of them felt having received the kind of service they had wanted. All the respondents felt that the
workshop had addressed some or most of their needs. They would also recommend the FPP to other
families coping with the care of a schizophrenic patient (M=3.35, s.d .48). In addition, the respondents
also gave clear approval for the FPP, indicated by the high overall satisfaction rating of 2.95 (n= 40, s.d
0.50).

All the participants felt that the workshop had been effectively in helping them cope with patient
management at home (M= 3.15, s.d .36), and would like to come back for more of such workshops
(M=3.30, s.d .46). At the same time, the participants also found all the components of the FPP to be
useful, namely, myths and etiology of the illness (M=3.20, s.d .61), symptomatology (M=3.40, s.d .59),
coping strategies (M=3.20, s.d .52), treatment methods (M=3.15, s.d .48), and community resources
(M=3.10, s.d .44). In an attempt to find out which of the components were superior in their ratings,
regression analysis tests found the differences not to be statistically significant.

It was hypothesized that family caregivers who had gone through the FPP workshop would be
more confident in managing the patient at home. Results indicated that 80% of the respondents felt more
confident after participating in the workshop, with a rating of 2.70 (n=40, s.d .79). The other remaining

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on4
Psychotherapy 12-15 March 2003, Suntec City, Singapore
20% however, did not report any improvement in their level of confidence. One plausible reason being
that the one-session workshop, was inadequate to address the anxiety and stress of the family member
who was in the caregiving role. Hence, it corroborates with the finding that 95% of the participants had
indicated a preference to participate in more such workshops in the future (n=40, M=3.30, s.d .32).
Correlational analysis found no significant relationship between the respondents’ level of knowledge
about schizophrenia, and their level of confidence in managing the patient at home.

Discussion & Implications for Practice

Overall, the FPP was very positively evaluated by family caregivers who participated in the
program. The results suggested that the FPP was an appropriate platform for addressing the caregiver’s
concerns about the illness through transmitting correction information about the illness, its treatment,
rehabilitation issues, and other issues related to management of a schizophrenic patients. Through this
program, family caregivers were empowered with knowledge about schizophrenia and its management,
which helped to enhance their confidence and reduce their anxiety in assuming the caregiving role.

It was particularly noteworthy that the program also provided an opportunity for family caregivers
to grieve over the loss of mental health of a family member and the group process also addressed the
feeling of self-blame amongst the family caregivers. They could see that schizophrenia is an illness that
is not caused by the family and that, they were not alone as there were also many other families who
shared similar experiences. Through sharing during the program, family caregivers now have more
realistic expectation of the patients. More importantly, for members to experience and to be experienced
by others as supportive through intangible behaviours, this enables them to learn the actual skills of
competently managing one’s feelings and developing pertinent problem solving strategies (Gitterman,
1989).

Thus, the findings from this study also lent support to other researcher’s belief that
psychoeducational module is the key or core element of community psychiatric rehabilitation as it offers
vital coping strategies and knowledge to caregivers to manage patients in the community. Therefore, an
effective family psychoeducation program properly integrated into the service delivery system would be
able to empower family caregivers to support their patient’s rehabilitation.

As the study found that family caregivers who declined to attend the program have lower level of
knowledge, as compared to those who agreed to participate in the program, this was suggestive that
these family caregivers were generally more apathetic towards the patient’s illness and its management.
Most of them seemed to be disappointed with the situation, and may probably living in denial to the fact
that the patient is suffering from a severe mental illness. In order to arrest the apathy of family caregivers,
the researchers feel that early intervention is crucial. Therefore, it is recommended that all newly
diagnosed cases, regardless of inpatient or out patient care, should be referred for family
psychoeducation as part of the holistic approach in treatment and rehabilitation of schizophrenic patients.

In general, family caregivers who participated in the family psychoeducation program have
indicated improvement in their level of confidence in managing patient and the illness, associated with a
more positive evaluation of their own self-efficacy. Despite the reported improvement in their self-efficacy,
the study had not been designed to include other corroborative measures to investigate the impact of the
program on changes in coping behaviour, level of family satisfaction or psychological well-being, and
rates of hospitalization of the mentally ill patients. Thus, the caveat raised by the researchers cautioned
on the sustainable effect of the family psychoeducation program, as it remained unmeasured. It would
therefore be logical to replicate another post-hoc study on the level of knowledge and self-efficacy of
these caregivers in a follow-up study three months after completing the family psychoeducation program.
Additional investigations into other variables, such as attitudinal differences between groups of
caregivers, styles of coping, level of health and psychological wellbeing of caregivers, and rates of
hospitalization of the patients, can also be included.

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on5
Psychotherapy 12-15 March 2003, Suntec City, Singapore
 It was apparent that participants of the family psychoeducation have indicated that finding all the
materials covered in the program relevant and useful, thus providing tentative evidence that the
educational materials developed by the various researchers were found to be relevant and suitable for our
local clientele. It was fairly reasonable to conclude that the materials used were comprehensive and had
addressed the main concerns of the family caregivers, given that the results were unable to identify which
of the specific components of the educational material to be more important than the others. In addition,
as the program also received high approval from the participants, it also suggestive that the didactic style
of disseminating correct information and structured discussions amongst the participants, were well
received by the local audience.

Since the program received good approval rating from the participants, it was no surprise that
these caregivers have emphatically indicated the preference for more of such help and were keen to
recommend others in similar situations to participate in the program. The prospect of long-term care for
schizophrenic patients and its demonstrated high burden of care found in many studies (Seng &
Bentelspacher, 2001; Papadoulos, 1995; Fadden et al, 1987; Gibbon et al, 1984) amplifies the critical
importance of mobilizing and organising good social support for the caregivers, in order to sustain and
prolong their continued involvement in the care and rehabilitation of the patients. Hence, the researchers
recommend promoting more and regular family psychoeducation programs as a vehicle to promote
adaptive change amongst the family caregivers. These family psychoeducation programs can be carried
out by other trained staff from the Institute, such as Commmunity Psychiatric Nurses. The Medical Social
Work Department, in collaboration with the Department of Community Psychiatry can also organise
similar workshops targeted at the general population in the community, to help raise awareness about
schizophrenia and its management, thereby addressing the general misconception that schizophrenic
patients are dangerous, with very poor prognosis. Moreover, through raising the awareness and dispelling
common misconceptions about the illness, additional avenues that enhance social support for the
caregivers will be made available for the caregivers, thereby enhancing their level of resilience in face of
the high burden of care for the patients.

Conclusion

This program of family psychoeducation has been impressive in its enthusiastic acceptance by
the participants. As such, the FPP could serve as a mean to form therapeutic alliance between the
patient’s family and the service providers. In the process of delivering the program, the group leader
could identify specific issues for follow-up services. Through this, a seamless continuum of care can be
transferred from the treatment facilities, eventually to family caregivers in the community, with the aim of
reducing the incidence of revolving-door syndrome amongst patients with frequent admissions.

Furthermore, in forming a therapeutic alliance, it is hoped that the service providers could
become working partners with family caregivers to offer support and guidance in times of crisis, rather
than mere responders to a problematic situation. Family caregivers no longer feel that they are facing the
situation alone and have information on resources available. Such a collaborative approach promotes
the involvement of the caregivers, to play a more proactive role, thereby enhancing their level of
responsibility and commitment in alleviating the distress caused to the family as a result of caring for the
patient. It is hope that this would reduce the incidence of rejection of patients by family caregivers.

Finally, the results of this study also highlight the importance of family psychoeducation as a form
of secondary prevention. It helps to demystify mental illness and to empower caregivers with crucial
coping strategies, in times of their vulnerability. In addition, the participants of the program also felt
supported, as their involvement would allow them to realize they are not suffering alone and all
participants are in the same boat. Their involvement is in itself, therapeutic!

Presented at the 6th Pacific Rim Congress of Group Psychotherapy and 3rd Asia Pacific Conference on6
Psychotherapy 12-15 March 2003, Suntec City, Singapore
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