P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l

An Evaluation of a Family
Psychoeducation
Program in Community
Mental Health
▼
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Lyn de Groot, Chris Lloyd

& Robert King
Lyn de Groot, BA, is with IMHS, Gold
Coast Health District, Southport.
Chris Lloyd, PhD, is with the
Department of Occupational Therapy,
University of Queensland,
Queensland.
Robert King, PhD, is with the
Department of Psychiatry, University
of Queensland, Queensland.
For information contact Chris Lloyd
at Department of Occupational
Therapy, University of Queensland, St
Lucia, Queensland 4072 Australia,
Email: c.lloyd@shrs.uq.edu.au
The aim of the research project was to identify the efficacy of the family psychoed-
ucation program as a strategy for reducing the hospital admissions of young peo-
ple. It also aimed to determine if the family psychoeducation program had an
impact on the experience of caregiving and knowledge and satisfaction of services
provided by the mental health service. A retrospective chart audit compared read-
mission history of 27 clients whose families attended a psychoeducation program
with readmission history of a matched group of young people whose families did
not attend the program. A telephone survey was conducted for both groups of fam-
ilies to investigate knowledge and understanding of services and burden of care.
The results indicated that family participation in a brief multiple family psychoedu-
cation program did not reduce the number or duration of admissions of the young
people. There was no impact on the level of care for families who attended the psy-
choeducation program, however, this group showed some evidence of increased
knowledge and understanding of services as compared to the control group.

Thank you to the people who

participated in the telephone
interview, to Danielle Montgomery for
her research assistance, and to Chris
Foley for his administrative support.
This research project received
funding from the Schizophrenia
Fellowship of South East Queensland
Sunflower Foundation and Professor
Philip Morris, Chair of the IMHS
Research Committee.
The role that families play in support
and care of their relative with a mental
illness has gained increased attention
in the past 30 years. This has been ac-
companied by research into the effec-
tiveness of psychoeducation programs
in helping families deal with the ill-
ness and the individual’s subsequent
wellbeing. Thus far, most research has
been into programs run over extended
periods of time under controlled re-
search conditions. Dixon, Adams, and
Luckland (2000) asserted that this is
costly and families and clinicians have
expressed concern about the time
commitment involved. They also point-
ed out that research settings have
highly trained staff and selected par-
ticipants. More research into low cost
programs run in usual practice set-
tings have been called for (Dixon et al.,
2000; Dixon et al., 2001). Additionally,
there has been little research into pro-
grams for families of relatives with a
recent onset psychotic disorder
(Gleeson, Jackson, Stavely & Burnett,
1999).
The aim of this study was to determine
the efficacy of a brief multiple family

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18

psychoeducation program as a strategy
for reducing hospital admissions for in-
dividuals with a recent onset psychotic
disorder. It also aimed to determine
if the program had an impact on the
experience of caregiving and knowl-
edge and satisfaction of services pro-
vided by the Gold Coast Mental Health
Service.
Literature Review
Since the 1970s there have been a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
number of different approaches to
working with families. These have in-
cluded the work pioneered by Leff et al.
(1990) designed to reduce expressed
emotion, a single family problem solv-
ing approach developed by Falloon et
al. (1985), brief single family psychoed-
ucation approach developed by Glick,
Clarkin, Haas, and Spencer (1993) and
the work with multiple family groups by
McFarlane et al. (1993). Each of these
approaches have a different emphasis,
but all have an eclectic mix with com-
mon characteristics which include: in-
formation about mental illnesses;
teaching and facilitating problem solv-
ing; emotional and practical support;
and interventions designed to modify
interpersonal relationships within the
family which are characterized by hos-
tility, intrusiveness or critical judge-
ment. There has been enthusiasm for
the generally positive findings of re-
search into family psychoeducation.
This has resulted in its recommenda-
tion for inclusion as best practice by
the Schizophrenia Patient Outcome
Research Team (PORT) (Lehman &
Steinwachs, 1998) and included in a
series of articles on “evidence based
practice” (Dixon et al., 2001).
However, two recent meta analyses of
family interventions by Pekkala and
Merinder (2001) who reviewed 11 stud-
ies between 1988 and 1991 and
Pharoah, Mari and Streiner (2001) who
reviewed 13 studies between 1978 and
S U M M E R 2 0 0 3 — V ol u m e 2 7 N u m b e r 1
1996 showed some disparity in effica-
cy. Pekkala and Merinder (2001) exam-
ined 10 group psychoeducation
interventions that included the individ-
ual in treatment and their families.
Findings were that psychoeducation
significantly decreased relapse and
were consistent with the possibility
that psychoeducation has a positive
effect on a person’s wellbeing. No
impact was found on insight, medica-
tion related attitudes or satisfaction
with services. It was concluded that
psychoeducational approaches are
useful as part of a treatment program.
Pekkala and Merinder (2001), in their
meta analysis, reviewed six studies
using brief (one to ten sessions) group
interventions. Measures on which brief
interventions indicate improvement in-
cluded a significant reduction of re-
lapse or readmission rates at nine to 18
months followup, some evidence sug-
gesting that increased knowledge of
the condition improved psychosocial
functioning and some suggestion that
psychoeducation may improve cooper-
ation with medication. Finally, family
members’ understanding of, and atti-
tudes to psychiatric illness, may be
positively affected up to four and a half
months, including significant changes
in expressed emotion status. No im-
pact was found on overall satisfaction
with services. Overall, in comparing six
brief with four standard length inter-
ventions, they concluded that it is not
possible to analyze whether different
duration of psychoeducation influ-
ences effectiveness.
Pharoah et al. (2001) examined studies
of five or more sessions of family inter-
ventions in community settings de-
signed to reduce levels of expressed
emotion. Seven studies included the
person in treatment and six involved
only relatives. The findings in this
analysis were more ambiguous. They
showed there might be a decrease in
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19
the frequency of relapse, but the trend
over time is towards the null. Further,
that family intervention may improve
general social impairment and levels
of expressed emotion within the family
and it may decrease hospitalization
and encourage compliance, but data
are few and equivocal. The reviewers
concluded that one couldn’t be confi-
dent of the effects of family interven-
tions from their findings.
The different findings in these reviews
may be related to the exclusion of the
person in treatment in some studies
or it may be related to Pekkala and
Merinder’s (2001) studies’ emphasis
being general psychoeducation, while
Pharaoh et al.’s (2001) studies were
related to an emphasis on expressed
emotion reduction, or a less obvious
factor or factors. Both reviews called
for larger, well designed trials and a
greater variety of outcome measures
to better illuminate the effects of inter-
ventions.
In a separate review of recent studies,
from 1993–1997, Dixon et al. (2001) ex-
amined three brief interventions of up
to four months. The analysis showed
mixed results for relapse reduction and
skills status but knowledge, attitude
and the quality of the relationship im-
proved. On the whole, and despite the
PORT (Lehman & Steinwachs, 1998)
recommendations that family psychoe-
ducation programs should be at least 9
months long, there appears to be some
evidence that brief interventions may
be efficacious in producing positive
outcomes. This is especially true in the
areas of knowledge of the condition,
family attitude and relationships and,
on balance, relapse rates.
There have been two recent reviews of
studies into the efficacy of programs
for families of individuals with a recent
onset psychosis. Dixon et al. (2000)
and Gleeson et al. (1999) together con-
sidered studies published between
 P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l
1978 and 1997. Six studies compared
relapse or readmission; two studies
compared expressed emotion and one
medication cooperation. The reviewers
reached similar assessments. That is,
no firm conclusions could be drawn,
partly because studies used varying di-
agnostic and relapse criteria; the key
influential elements of interventions
need to be isolated; and the interven-
tions need to be tailored for the recent
onset phase of illness. In particular, in
considering the results from the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Linszen et al. (1996) study, it would
appear that families require an oppor-
tunity to deal with their emotions and
to attempt to modify this process
may be associated with detrimental
consequences.
Aim
The aim of this study was to investigate
whether a brief multifamily psychoedu-
cation program for families of individu-
als recently diagnosed with a psychotic
illness and run in a usual practice envi-
ronment would have an impact on
readmission rates, the experience of
caregiving and knowledge and satis-
faction with services.
Method
Design
The research was a quasi-experimental
study with a matched control group
using a retrospective chart audit and a
telephone survey.
Participants
The treatment group consisted of fami-
ly members of 27 individuals with a re-
cent onset psychotic disorder who had
been admitted to the Gold Coast
Hospital inpatient facility. The control
group consisted of family members of
27 individuals who had been admitted
with a similar history and similar time
of admission but had not participated
in the program. These were matched
An Evaluation of a Family Psychoeducation Program in Community Mental Health
Table 1—Characteristics of Participant and Control Groups
Participants with
Family Psychoeducation Control
Mean age 26 26
% male 88.5 88.5
% schizophrenia 69.8 65.4
Mean admissions 2.8 2.5
Days of admission 62.5 54.9
according to diagnosis, duration of ill- groups were exploring family concerns;
ness, gender, age, time and length of providing support; and facilitating
admission. Characteristics of the two problem solving.
groups are set out in Table 1. Of the 28
Measures
families that attended the program, 27
Hospital charts and computer records
were included in the treatment group.
were reviewed to determine demo-
One family was excluded due to death
graphic information and readmissions.
of the relative. Of the remaining fami-
The information that was collected in-
lies, 16 (59%) were contacted and
cluded age, gender, and diagnosis at
agreed to participate in a telephone
the time of the referral to the program
survey. Others were not included be-
and whether they were referred for re-
cause they either could not be contact-
habilitation, supports management
ed (7%) or declined to participate
(case management in Australia), and
(33%).
medical followup. Additional informa-
Intervention tion was collected on length of stay,
The program consisted of three phas- number of admissions, family constel-
es: an initial interview with family lation, whether they had siblings at
members, a full day educational work- home, place of residence, illicit sub-
shop, and a multifamily group held for stance use, and when their family at-
2 hours fortnightly for 5 months. There tended the program. Records were
were six cohorts with an average of examined for a 7-year period.
four families per cohort. There was
The Family Psychoeducation Survey
some variation in the content of work-
consisted of the Experience of
shops and multifamily groups, reflect-
Caregiving Inventory (ECI) (Szmukler,
ing changes in personnel and approach
Burgess, Herrman, & Benson, 1996)
over time. Common content of the
and a measure of knowledge, self-effi-
workshops consisted of education and
cacy and service satisfaction, devel-
information about psychosis and early
oped specifically for this study. The ECI
warning signs; treatment and medica-
contains 66 items and 10 subscales
tion; behavioral strategies; information
and has been used in previous studies
about community resources and the
investigating the impact of family sup-
mental health service; balancing family
port interventions (Harvey, Burns,
needs with the needs of the person in
Manley, & Tattan, 2001; Joyce, Leese, &
treatment; and career perspectives.
Szmukler, 2000; Szmukler et al., 1996;
Common elements of the multifamily
Treasure et al., 2001).
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20

This new measure of knowledge,
self-efficacy and service satisfaction
contained two subscales with each
scale consisting of 13 items. Items
were piloted with members of the
Schizophrenia Fellowship Carer
Support Network who had not been
involved in the program but who had
contact with the mental health service.
In each instance respondents used a
four point Lickert scale.
The first scale measured knowledge
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
and self-efficacy for aspects of illness,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
service response and self-care. The
content reflected psychoeducational
aims that were consistent across all
cohorts and therefore had face validity.
Examples of some of the items include:
how well do you understand the kinds
of medication used in treatment of
your family member, can you identify
early warning signs that could indicate
your relative is at risk of relapse, when
accessing a public mental health ser-
vice do you understand the process for
hospital admission, and how often do
you do things that you enjoy as distinct
from looking after the needs of others.
Reliability as measured by internal con-
sistency was acceptable at alpha = .79
(n = 28). The second scale consisted of
items designed to measure satisfaction
with the mental health service.
Examples of some of the items include:
access to doctors, support provided by
staff to your ill relative, support provid-
ed by staff to family members, informa-
tion provided by staff about your
relative’s illness, and communication
with you about treatment plans, includ-
ing discharge from hospital. Reliability
of this scale as measured by internal
consistency was very high at alpha =
.96 (n = 29). It should be noted that the
small sample sizes require that reliabil-
ity be viewed with some caution.
Procedure
A telephone survey was conducted
with the families and control group to
S U M M E R 2 0 0 3 — V ol u m e 2 7 N u m b e r 1
determine the families’ knowledge
related to psychotic illness, treatment
accessibility, and the experience of
caregiving. The interviewer was inde-
pendent of the Gold Coast Hospital,
and used the standardized interview
schedule described above that includ-
ed the ECI and the two new scales de-
veloped for this study.
Results
For purposes of this study, the index
admission was the admission that im-
mediately preceded commencement of
family psychoeducation for the study
group. For the control group it was an
admission that took place within the
same period as a matched individual
from the study group. The study group
and the control group had comparable
rates of admission prior to the index
admission. The study group had a
mean of 2.80 admissions prior to and
including the index admission and the
control group had a mean of 2.50 ad-
missions prior to and including the
index admission. Days of inpatient
treatment were also compared for the
two groups. The individuals in the
treatment group had a mean of 62.10
days of admission prior to and includ-
ing the index admission and the indi-
viduals in the control group had a
mean of 54.90 days of admission prior
to and including the index admission.
T-tests for independent samples were
conducted to determine whether or not
this difference was significant and this
analysis returned a negative finding
(t = 0.39, df = 50, p = 0.70).
During the follow-up period, 16 individ-
uals were readmitted to the psychiatric
unit and 36 individuals had no admis-
sions. Of those readmitted, nine were
from the study group and seven were
from the control group. Investigation
of the distribution of admission versus
non-admission for study and control
groups using chi-square demonstrated
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21
that there was no difference between
the groups (
2= 0.36, df = 1, p = 0.55).
Number of days in inpatient care
following the index admission for
the two groups was also investigated
using analysis of variance with days of
inpatient care prior to and including
the index admission as a covariate.
There was no difference between the
two groups (F= 0.92, df = 1, p = 0.34).
The overall response rate to the tele-
phone survey was 78% (29), treatment
group 84% (16), and the control group
72% (13).
Independent sample t-tests were used
to compare means for the study group
and the control group with respect to
each of the 10 subscales of the ECI. In
each instance mean differences were
small and non-significant. There was
neither a pattern nor a trend that
would indicate a larger sample would
show significant differences between
the groups.
Independent sample t-tests were used
to compare means for the study group
and the control group with respect to
scale score totals for Knowledge
and Self-efficacy and for Service
Satisfaction. Although mean scores
suggested that the study group had
greater knowledge and self-efficacy
and higher service satisfaction than for
the control group, in neither instance
were differences significant.
In the Knowledge and Self-efficacy
scale, two items showed a significant
or close to significant mean rank differ-
ence between study and control
groups, using Mann-Whitney U-tests.
The study group believed they knew
who to call for help more than the con-
trol (Mann Whitney U = 54.50, p = 0.02)
and the treatment group indicated
greater understanding of the role of the
support manager (Mann-Whitney U =
62, p = 0.05).
 P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l
With respect to satisfaction with ser-
vices, the study group was more satis-
fied with the amount of treatment and
rehabilitation provided (Mann-Whitney
U = 57.50, p = 0.03) and with informa-
tion about treatment and services pro-
vided by the mental health service
(Mann-Whitney U = 57.50, p = 0.03)
than was the control group. There was
also a trend for the study group to be
more satisfied with information about
community resources, and with the
level of support provided by staff to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
family members.
Discussion
This was an underpowered study with
some methodological weaknesses (see
below) but we think that the major find-
ing of limited impact, either on clinical
outcomes or on the relationship of the
family to the mental health service, is
probably sound. There may be a num-
ber of reasons for the very limited im-
pact that the family psychoeducation
program had on reducing hospital
readmission rates, experience of care-
giving and satisfaction with services.
This program did not include the per-
son in treatment in the groups. Many of
the programs shown to impact on read-
mission rates include the person in
treatment in the groups (Pekkala &
Merinder, 2001).
Another factor that might explain the
limited impact is that the program was
provided in a standard clinical environ-
ment rather than in a research environ-
ment. There is a consistent finding that
program impact in clinical settings is
less than in research settings (Harrison
& Eaton, 1999; Lehman & Steinwachs,
1998; Torrey et al., 2001). In this in-
stance the program itself was less
standardized than would be in a re-
search as distinct from clinical environ-
ment. The group facilitators changed
over time and were without training in
any particular model of psychoeduca-
An Evaluation of a Family Psychoeducation Program in Community Mental Health
tion. There was some variability in pro- relatively low readmission rate (30%)
gram content, with the constants being lends some weight to this.
information, support, ventilation, and
The results of this study are consistent
problem solving. This “usual practice”
with Dixon et al.’s (2000) assertion that
environment is quite different to the
brief programs may influence knowl-
conditions under which many of the
edge, attitudes and the quality of rela-
family psychoeducation studies have
tionships but to reduce relapse,
been conducted where staff is highly
programs need to be of longer dura-
trained, participants are selected, and
tion, at least 9 months. However,
conditions are controlled (Dixon et al.,
results were not consistent with the
2000).
findings of the meta analysis by
Clinicians’ work schedules also placed Pekkala and Merinder (2001) that
constraints on what they considered showed significant reductions in re-
ideal practice. They usually only met lapse rates with brief interventions.
once with the family prior to the work-
shops, which may not have been held
Methodological Limitations
for several months in the future. This
provided limited support to the family The study had two major methodologi-
when it may have been most crucial, cal weaknesses. First, it was a retro-
especially for families of recently spective study with a matched rather
diagnosed young people. Gleeson et than randomized control group. In any
al. (1999) made the point that interven- such study the possibility exists that a
tions for families of recent onset rela- systematic factor not identified for pur-
tives need to match the readiness of poses of matching is confounding re-
the family. If the family was ready and sults. This would be a more serious
nothing was offered, the opportunity objection in the event of a more posi-
may be lost for the program to be tive finding because it could be argued
meaningful. that factors motivating a family to un-
dertake a psychoeducation program
Dixon et al. (2000) submitted that it is
contribute to outcome. The predomi-
important to consider the comparison
nantly negative findings of this study
or standard model of treatment provid-
are less able to be explained in terms
ed, as this may also be as effective in
of motivational or other factors that
reducing relapse rates as any added
contribute to participation. The second
value of family psychoeducation. This
major weakness relates to sample size.
may have been a factor mitigating
Given the trends for the study group to
against specific family psychoeduca-
show more positive response on some
tion effects in this study. The mental
items measuring knowledge and self-
health service uses an assertive com-
efficacy and satisfaction with services,
munity support management model
it is possible that a larger sample
that includes collaboration with the
would reveal more systematic and sub-
person in treatment and their carers. It
stantial psychoeducation effects in
also has an assertive and innovative
these domains. However, there is no
rehabilitation program tailored to indi-
reason to suspect that a larger sample
viduals’ interests, abilities and phase
would reveal effects on clinical out-
of recovery. It is possible that such ser-
come or on level of care, as there were
vices, accessible by the control group,
no discernable trends in either of these
were sufficient to reduce readmission
domains.
to the full extent that was possible. The
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22
 S U M M E R 2 0 0 3 — V ol u m e 2 7 N u m b e r 1

We do not think that either of these
limitations seriously compromises the
findings or conclusions that can be
drawn from this study. However, the
small sample size and associated weak
translating findings from research into
a usual practice environment. It is evi-
dent more research needs to be con-
ducted in usual practice environments
to determine what elements of family
Lehman, A., & Steinwachs, D. (1998). PORT co-
investigators. At issue: Translating
research into practice: The schizophrenia
patient outcome research team (PORT)
treatment recommendations.
Schizophrenia Bulletin, 24, 1–10.

statistical power raises the possibility
that the impact of family psychoeduca-
tion on service knowledge, self-efficacy
and service satisfaction is greater than
we have reported.
Further Research
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
psychoeducation have benefits for the
families of young people with psychotic
disorders.
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about treatment, the mental health ser-
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