Previous brief education programmes such as the one used in the Tarrier and Barrowclough research (Barrowclough et al., 1987; Tarrier et al., 1988a), and many reviews (Pitschel-Waltz et al., 2001) have concluded that education alone does not reduce EE or affect relapse, but it has been found that brief interventions can produce immediate increases in family members’ knowledge (Birchwood et al., 1992; Cassidy et al., 2001; Linszen et al., 1996; Moxon & Ronan, 2008; Mullen et al., 2002), increases in general coping, and to an extent alleviate family members’ burden and distress (Abramowitz & Coursey, 1989; Lam, 1991; Merinder, 2000; Posner, Wilson, Kral, Lander et al., 1992). This study found that education perhaps combined with some other non-specific factors can reduce EE, burden of care and distress to a degree which can be maintained at a 9-month follow-up. Over the course of the current study, there were significant reductions in EE, which were either maintained or, in the case of family members’ intrusiveness, continued to improve over a nine-month follow-up interval. Here, reductions in EE appeared to be due largely to education.
One question here is why did EE decrease in this study when it has not in other studies with the sole exception of the Moxon and Ronan (2008) study that this replicated. As discussed earlier, it is quite possible that as a function of being connected to a community support agency as well as based on voluntary participation, participants entered the study with a certain mindset, level of motivation, and expectations. For those in the control condition, there was quite possibly anticipation that someone within a familiar setting who seemed to understand their situation was going to put aside time to listen, and discuss on a knowledgeable, empathic and one-to-one basis. Positive expectancies, and perhaps the effect of retesting, may have been sufficient to produce some non-significant changes in various indicators during the control period.
It is possible that the anticipation of participating in the intervention led to a reduction of EE, burden of care and distress as well as an increase in coping. All participants at the outset of the study discussed it with the author. Each participant was told that they would receive information about schizophrenia, expressed emotion, and techniques that other families have found helpful in not only coping with the client on a daily basis, but to aid them as well. Perhaps the idea that this study could help was part of the reason for the decrease. Some clients stated that it might be beneficial for their family member to participate as it may help lower their feelings of guilt and responsibility about the illness, stop them from ‘nagging’ and help
them to see more from their point of view. Some family members stated that it would be beneficial for clients to participate as the helpful techniques given may help if heard from a non-medical type person or authority figure. Perhaps the initial information coupled with expectancy effects that were further magnified by the self-assessment and reflection required for the pre-test measures – in a sample of motivated participants - may have combined to promote some cumulative effect. Such factors might then have been sufficient to begin to lower EE, burden of care and distress while increasing perceived coping during the control interval.
It is also possible that the beneficial changes achieved during the course of the intervention itself were due in part to the design of this particular protocol and to the additional focus of the second part of the education programme. The second half of the education programme focused on providing validation to participants in how they may be feeling in response to the illness, in addition to reassurance that they are not alone in learning to cope with and manage it. Information was also provided on the value of a low-stimulus environment, as well as coping techniques and self-care strategies, all proven to have had a modicum of success with people in similar situations. Encouragement of participants to become actively involved was particularly provided for this component of the intervention, as was the exposition on particular areas identified as weaker in the pre-test measures. This additional focus may have contributed to a mutual reduction in EE levels (of both client and family member) as well as a reduction in family members’ subjective burden of care.
This study also differs from other brief interventions in that it was conducted in New Zealand and it was not conducted in a research-based setting. The positive results achieved here likely were influenced by this study being conducted through community organizations who believe in, support and practice the principles advocated in the intervention. All participants were members of, or affiliated with the organizations, although not all participants were actively involved with the agencies. It is highly likely that the community setting helped produce an atmosphere conducive to both increased expectancies as well as actual change. More research is needed to examine whether there is more direct data-based support for the potential of community organizations to influence the way clients and families perceive, react to and manage this disorder on a daily basis.
The professionals administering the measures were agency field or key-workers, and the author (a PhD student in psychology) conducted the education. These people were not clinicians and all saw the participants in their nominated venue where they felt most
comfortable. They did not appear to be threatening or intimidating, and all made themselves available for queries, concerns, or support. It was also suggested during the intervention that it would be of benefit to utilise the appropriate fellowship for additional resources, knowledge and support. Perhaps this was a more laid-back (though still experimentally rigorous) approach than previous clinical trials resulting in a more relaxed atmosphere for participants.
When considering reasons for the success of this intervention, in addition to the intervention itself, the delivery also should be considered. That is, the author of the study is another possible factor in the results of the intervention. The author/educator had gathered by the close of the intervention 13 years practical experience working in the mental health field and 12 years research experience over the course of the two research projects (Masters and PhD). It is likely that this influenced the ability to be flexible and for the intervention to be tailored according to each participants pre-test information. This may have been due to the amount of comprehensive and up-to-date knowledge about schizophrenia coupled with clinical experience gained from working in the field. Any future research would need to ensure that educators had a similar wealth of knowledge and experience to be able to effectively implement a flexible education programme. Additionally, in studies that have multiple therapists, including the therapist as a variable in future research would also be desirable to start addressing questions that revolve around the level of experience and skills required for useful delivery of this and related programmes.
The difference of results between previous studies and the Moxon and Ronan (2008) and present study could also have been influenced by a cultural difference. Future research would benefit from conducting the same study in different environments (e.g., inpatient settings, outpatient settings, community support settings) in different cities and regions throughout N.Z. (i.e., Auckland, Hamilton, Dunedin, and Christchurch) as compared to different countries.
In summary, in terms of an overall direction for future research, with support now from two RCT evaluations that have produced a similar pattern of findings, a next step may be to begin identifying and isolating more precisely what the therapeutic elements are in this intervention.