Further analyses were conducted in relation to EE to establish if the treatment produced decreases in EE were dependent upon whether the person was initially rated as high-EE or low- EE. It was found that the family members’ and clients’ Total scores on the LEE were dependent to a degree on whether the participant was initially rated as high-EE or low-EE. While both
changed significantly, the interaction effect reflected greater significant change, after treatment for high-EE family members. This is not surprising as overall, high-EE participants had more room to alter their scores than low-EE participants who had limited change potential given they were already low-EE at the outset of the study.
On the other hand, a lack of interaction effects indicates that low-EE family members can also obtain benefit from education designed to promote understanding and coping strategies. A rating of EE does not denote a problem- or stress-free household. Tarrier et al., (1988a) caution that it would be misleading to assume that any family member of someone diagnosed with schizophrenia is without stress or difficulties. It can be suggested that if low-EE families do not receive any support, they might be more prone to develop high-EE behaviours such as critical and intrusive attitudes. It has also been theorised that some low-EE behaviours such as a lack of criticism, overinvolvement or the adoption of an ‘ignore/accept’ style of coping may sometimes be due to exhaustion and a function of burnout (Barrowclough & Tarrier, 1992). The fact that no family members changed from low- to high-EE status over the course of the study indicates that a brief education programme may also be useful as a preventive measure.
Barrowclough and Tarrier (1992) concluded that brief education has value in engaging the family in treatment, helping them to assimilate schizophrenia and its problems from a stress vulnerability framework. Pakenham and Dadds (1987) found that brief interventions have value as they can lead to increased understanding and short-term reduction of family burden, distress, and anxiety, but not to a reduction in EE. Cozolino et al. found no increase in knowledge in their 1988 study, yet family members did report an increased sense of support and decreased feelings of personal guilt. In their 1989 study, Abramowitz and Coursey found results including a more effective management of home life and reductions in self-reported distress and anxiety. However, none of these effects lasted to six month follow-up intervals.
It is important to note that no brief intervention other than Moxon and Ronan (2008) and the current study to date has found immediate or longer term reductions in EE. Given EE literature and its impact on increased frequency and duration of client relapse (Marom, Munitz, Jones, Weizman, & Hermesh, 2005), this finding is encouraging. If replicated and particularly given the significant impact on family members’ intrusiveness toward the client, combined with increased knowledge, implementing brief education programmes within supportive community organisations appears to have potential.
FQ
The third aim of the present study was to see whether brief education carried out in a community setting would lead to decreases in family members’ perceived burden of care and distress and increases in family members’ perceived ability to cope. It was hypothesised that the provision of information would lead to change in these three variables. This was assessed in two ways: firstly, through a comparison of treatment and control group scores before and after the education, and secondly by examining whether family members’ initial EE status affected these variables. The results were positive with significant change found across treatment groups.
As seen in the Results section, analyses comparing treatment and control conditions showed that there was a significant decrease from pre-test to post-test in burden of care and distress as well as a significant increase in perceived ability to cope. However, significant trials effects and the lack of interaction effects suggests, as with the EE result, that these changes were independent to a degree of whether family members were in Treatment Group I or the wait-list control group. Similar results have been found in longer psychoeducational interventions such as in the Magliano et al. (2006) study which found in their six month intervention that family burden was significantly reduced in both the treatment and wait-list control groups. However, it is in contrast with most other long-term interventions assessing familial burden of care and carer distress (Canive et al., 1996; McDonell et al., 2003; Mueser, Sengupta, Bellack, Glick, & Schooler, 2001; Solomon, 1996).
A short-term improvement in burden of care and carer distress has also been found in other educational interventions that are shorter than ten sessions (Abramowitz & Coursey, 1989; Berkowitz et al., 1984; Lam, 1991; Posner, Wilson, Kral & Lander, et al., 1992; Smith & Birchwood, 1990) but in most of these studies an increase in distress reoccurred after six months (Birchwood et al., 1992; Smith & Birchwood, 1990). In addition it is difficult to compare the present study with these as in addition to the present study being very brief at only two hours duration, it also involved the client in the intervention which many of these studies did not.
With all this said, as with the EE result, the majority of variance accounted for in the significant trials effects was in all cases accounted for by the treatment condition, with the
magnitude of change following treatment being much greater than that following the control period. Thus, the pattern overall indicates that following the intervention family members felt less burdened by client behaviour previously rated as problematic, felt less distressed by it and felt more in control and able to cope with these behaviours. If one was to combine this finding with the significant post-follow up finding for clients and family members in the Intrusiveness subscale of the LEE, a speculation is offered. This finding of family members becoming less intrusive and overinvolved over the follow-up period, allowing clients to have more control over their own lives, could be linked to an adoption of an “ignore/accept” style of coping indicative of low-EE families following treatment. Future research could more definitively focus on this issue with a larger sample size. Finally, combined with EE findings and with previous research findings (Moxon & Ronan, 2008), this overall pattern of findings implicates various issues include statistical power, expectancy and setting effects and sampling bias. As a consequence, future studies might pay attention to these factors.