LAPORAN PRAKTIKUM REVIEW CINEMA EDUCATION

“BEAUTIFUL MIND”

KEPERAWATAN KELUARGA

oleh:
Kelompok 2
Kelas B-2016
Faizatul Mazuin NIM 162310101051
Riris Nur R. NIM 162310101054
Tania Lestari NIM 162310101090
Maulidatul H. NIM 162310101092
Venti Kristian U. NIM 162310101098
Afni Nahdhiya D. NIM 162310101102

PROGRAM STUDI SARJANA KEPERAWATAN

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
2018
A. KEHADIRAN KELUARGA
1. GAMBARAN SINGKAT TENTANG FILM (SEBUTKAN
ANGGOTA KELUARGA DALAM FILM DAN DESKRIPSIKAN
KHUSUS ANGGOTA KELUARGA YANG AKAN MENJADI
PASIEN)
a. Anggota keluarga
1. Suami/ Pasien : John Nash
2. Istri : Alicia Nash
3. Anak : Tidak terkaji Namanya
b. Peran figuran
1. Dokter : dr. Rosen
2. Teman halu : William Parcher
3. Teman halu : Charles Herman
4. Teman halu : Marcee
5. Teman kerja : Sol dan Bender
c. Anggota keluarga yang akab menjadi pasien: John Nash
Dalam film A Beautiful Mind ini menceritakan seorang pria
mahasiswa jurusan matematika di Universitas Princeton bernama
John Nash yang memiliki kepandaian sangat jenius, namun dalam
keseharian nya ia kurang dalam bersosialisasi. Ia nampak terlihat
aneh saat pertama kali datang di Universitas Princeton pada diri
John. John memiliki seorang teman sekamar yang tidak nyata
bernama Charles Herman, padahal satu kamar di Princeton hanya
untuk satu orang mahasiswa. John menjadi dosen bersama kedua
orang temannya Sol dan Bender. Tak lama saat menjadi dosen john
bertemu dengan wanita cantik yang bernama Alicia lalu ia
memutuskan menikah karena saran yang diberikan oleh charles.
Kemudian mereka menikah dan mempunyai seorang putra. Saat itu
Ia juga bertemu dengan agen misterius dari departemen pertahanan
bernama William Parcher. Kemudian atas bujukan Parcher, John
bergabung dengan departemen pertahanan Amerika di Pentagon
yang bertugas untuk memecahkan sebuah kode-kode komunikasi
rahasia dalam majalah dari pihak lawan, yaitu Uni Soviet. John
selalu merahasiakan kegiatannya. Karena sikapnya tersebut istri
pun makin curiga terhadap perilakunya. Kemudian saat sedang
mengajar di Universitas Harvard, datang seorang Psikiater bernama
dr.Rosen untuk mengungkap dan menyembuhkan dirinya dari
Schizofrenia. Istrinya baru mengetahui setelah Jonh sudah ada di
Rumah Sakit Jiwa dalam perawatan. Ia kemudian diidentifikasi
oleh dr.Rosen lalu terungkap bahwa John berhalusinasi menyakini
dirinya bekerja pada departemen pertahanan sebagai pemecah kode
Uni Soviet dan mengenal tokoh-tokoh fiktif ; Charles, Marchee dan
Parcher.

Saat john berada dirumah sakit, dr.Rosen memberikan

terapi syok insulin kepadanya, John pun terlihat kembali normal
dan menyetujui untuk menjalankan pengobatan antipsikotik
seumur hidup, hingga Ia mengalami disfungsi seksual. John pun
merasa frustasi dan tak lagi meangkonsumsi pil yang diberikan
oleh istrinya hingga mengalami kekambuhan psikosis kembali
denga kembali munculnya Charles, Marchee dan Parcher beserta
misi-misinya. Hingga kemudian Alicia mengetahuinya dan saat
John tengah memandikan putranya. Alicia menemukan gubuk di
hutan belakang rumah yang dijadikan markas John dan bergegas
menuju rumah hendak menemui putranya yang hampir tenggelam
dalam rendaman air di bak mandi karena John sibuk dengan tugas
rahasianya dan John mengatakan bahwa Charles yang sedang
mengawasi putranya. Adanya kejadian tersebut Alicia pun kembali
menghubungi dr.Rosen dan mengirimkannya kembali ke rumah
sakit jiwa. Maka terjadilah perdebatan antara John dan Alicia
dengan ditambah munculnya Parcher yang menasehati John untuk
membunuh Alicia. John pun menolak perintah Parcher dan
mendorong istrinya menghindar dari tembakan Parcher. Alicia pun
marah dan ingin pergi dari rumah, tetapi John menghalang-
halanginya dan berusaha mengatakan dirinya telah sadar dengan
mengatakan bahwa semua itu benar hanyalah halusinasi dirinya
dimana dibuktikan dari Marchee yang tidak pernah dewasa.
Akhirnya, John dan Alicia memutuskan untuk hidup bersama
dengan kondisi abnormal itu tanpa perlindungan obat antipsikotik,
dan John mengatakan perpisahan kepada Charles, Marchee dan
Parcher. Namun bayangan mereka tetap saja dirasakan oleh John,
tetapi John tetap berusaha untuk melawan halusinasinya sendiri.
John Nash pun kembali bekerja di departemen matematika
Princeton atas bantuan sobat sekaligus rivalnya terdahulu pada saat
usianya menjelang lansia, dimana gejala Schizofrenia pada
akhirnya dapat dikendalikan dan cenderung semakin berkurang.
 2. GAMBARAN ECOMAP KELUARGA TERSEBUT

Kampus

John Alicia
Nash Nash
Rumah
sakit

Anak

Tempat
kerja

Dunia Fantasi

( Halusinasi)

Keterangan :

Laki-laki Tinggal Serumah

Perempuan Garis Pernikahan

Pasien Garis Keturunan

3. ANALISIS ECOMAP SECARA SPESIFIK TERKAIT
HUBUNGAN KELUARGA DAN LINGKUNGAN SEKITAR
Dalam sebuah ecomap tersebut hubungan antara Tn. John Nash
dengan istrinya Alicia sangat kuat ditandangi dengan Alicia yang
sangat sabar dan setia membantu suaminya dalam mengatasi masalah
penyakitnya yaitu skizofrenia. Selain itu John juga sangat mencintai
istrinya begitupun sebaliknya Alicia juga sangat mencintai suaminya
walaupun pernah terbesit dalam pikirannya untuk meninggalkan John
saat mengalami skizrofrenua. Keluarga ini juga memiliki latar
pendidikan dan karir yang baik. Dilihat dari John yang berpendidikan
sebagai lulusan di salah universita yaitu jurusan matematikan dan
akhirnya menjadi seorang dosen dengan delar doktor, begitu juga
dengan Alicia yang sempat menjadi mahasiswa disalah satu universitas
dengan jurusan fisika. John lebih sering menghabiskan waktunya di
tempat kerja yaitu sebagai dosen di salah satu universitas. Begitupun
dengan Alicia juga sering menghabiskan waktunya untuk bekerja,
namun dalam film tidak dijelaskan secara rinci pekerjaan Alicia itu
apa.
Saat John duduk di dunia perkuliahan, John mengalami delusi yaitu
dia mempunyai teman sekamar yaitu bernama charless, padahal
diasramanya bahwa dalam satu kamar hanya diisi oleh satu orang,
selain itu John juga berkomunikasi dengan keponakan charless yaitu
marcee. John sangat sayang terdapat Marcee, menganggap Marcee
seperti saudaranya sendiri. John juga berdelusi bahwa dirInya bekerja
pada departemen pertahanan sebagai pemecah kode rahasia. Saat John
diidentifikasi mengidap skizofren, John ditemui oleh salah satu tenaga
medis Rumah Sakit jiwa untuk membawa John menjalani perawatan di
Rumah Sakit tersebut, namun John menolak untuk dibawa oleh para
tenaga medis. Tetapi John tidak bisa berbuat apapun karena tenaga
medis yang sangat banyak saat melakukan penangkapan terhadap John
di tempat kerjanya.
B. PENILAIAN KELUARGA DAN PRIORITAS KEBUTUHAN
1. KONDISI FISIK DAN PSIKOSOSIAL
a. Kondisi fisik : Kondisi fisik John Nash dan keluarga terlihat baik.
Namun saat penyakitnya kambuh John nampak mengalami perubahan
fisiknya seperti mata cekung dan terdapat luka di tangan kirinya
b. Kondisi psikososial : kondisi psikososial dari John Nash Sedikit
kurang baik. John Nash sering diejek oleh teman nya karena
keanehann saat berada dikampus ya. Hingga akhirnya John Nash
diketahui mengidap penyakit Skizofrenia. Kelurga John Nash kaget
akan penyakit yang dialaminya serta tidak terima dan mencoba untuk
membuktikan bahwa apa yang dikatakan oleh John Nash itu nyata,
namun istri John Nash berhasil mendapatkan bukti jika suaminya
mengalami delusi, lalu ia mencoba menerimanya serta membantu
dalam perawatan suaminya. Istrinya selalu mendukung kegiatan John
Nash dan mendorong John Nash untuk melakukan hal lebih yang
dapat dia lakukan serta selalu mengingatkan bahwa yang dialami
suaminya adalah tidak nyata hingga akhirnya John mengalami
perubahan yang lebih baik
2. FAKTOR LINGKUNGAN DAN SOSIOKULTURAL; NILAI,
KEYAKINAN, SPRITUAL
Faktor lingkungan terlihat ketika berada di universitas princeton
tampak pergaulan anak muda pada umumnya. Pergi ke bar, bermain
checkers dan lain-lain. John Nash juga tetap belajar ketika berada di bar.
Untuk faktor nilai, keyakinan dan spiritual tidak dijelaskan secara rinci.
Namun ketika John Nash menikah terlihat keluar dari sebuah gereja
dengan dihadiri oleh beberapa teman nya.
3. STATUS GIZI DAN OBAT-OBATAN
Status gizi tidak dijelaskan secara rinci, baik pola makan ataupun makanan
yang dikonsumsi. Namun, John Nash mengaku kepada teman sekamarnya
jika dia makan ketika sempat. Namun kebiasaan untuk minum bir dan
 merokok masih ada dan wajar bagi budaya nya. Saat mengalami
Skizofrenia John mendapatkan pengobatan terapi syok insulin dan obat
antipsikotik
4. PENGGUNAAN SUMBER PERAWATAN KESEHATAN ATAU
PENGOBATAN ALTERNATIF
Ketika John Nash mengalami gangguan delusi yang parah saat
memberikan workshop, John Nash dibawa ke rumah sakit jiwa untuk
dilakukan perawatan.
5. DIAGNOSA MEDIS
Skizofrenia
6. BAGAIMANA KONDISI KLIEN MEMPENGARUHI KELUARGA
DAN REAKSI MEREKA
Kondisi klien sangat mempengaruhi keluarga, yang pertama yaitu
mempengarui seorang istri yang awalnya tidak menerima kenyataan jika
suaminya mengidap skizofrenia, namun akhirnya menerima dan
mendukung penuh kegiatan suaminya dna membantu untuk kesehatan
suaminya menjadi lebih baik, dengan cara selalu mengingatkan suaminya
untuk meminum obatnya. Serta mempengarui kondisi keselamatan
anaknya yang hampir celaka karena kelalaiannya.
7. PERSEPSI KELUARGA TENTANG KESEHATAN
Keluarga John Nash termasuk ke dalam keluarga yang
memperhatikan kesehatan. Terlihat ketika istrinya mendapati hal aneh
pada suaminya, sang istri langsung menelfon psikiater untuk mengetahui
kondisi suaminya yang sebenarnya, mengingatkan untuk selalu meminum
obat antipsikotik dan menyuruh John untuk menghardik ketika ia
mengalamu delusi
8. KEKUATAN KELUARGA
Keluarga John Nash sangat mendukung John Nash untuk
mendapatkan kemajuan dan tidak memperparah penyakitnya. Dengan
dibantu kembali untuk beraktivitas di universitas dan selalu diberikan
semangat ketika John Nash merasa rendah dan tidak mampu.
 C. IDENTIFIKASI PERMASALAHAN KELUARGA
DATA DIAGNOSA RENCANA TINDAKAN JURNAL
MALADAPTIF KEPERAWATAN KEPERAWATAN KEPERAWATAN / TERAPI RUJUKAN
KELUARGA
Do: Resiko perilaku Teknik menenangkan 1. Mempertahankan sikap Khalil, A.H., El-
-klien melukai kekerasan terhadap (5880): tenang dan hati-hati Nahas, G., Ramy, H.,
tangannya sendiri. orang lain b.d 1. Pertahankan sikap 2. Meyakinkan keselamatan
Aziz, K.A., Elkholy,
-klien tidak mau gangguan psikologis tenang dan hati-hati dan keamanan klien
meminum obatnya dan waham 2. Yakinkan 3. Mengidentifikasi orang- H., El-Gamry, R.
sehingga keselamatan dan orang terdekat klien yang 2018. Impact of a
wahamnya keamanan klien bisa membantu klien.
Culturally Adapted
kembali atau 3. Identifikasi orang- 4. Menentukan care giver
kambuh. orang terdekat yang konsisten setiap hari Behavioural Family
-klien klien yang bisa 5. Memberikan klien Psychoeducational
meninggalkan membantu klien. kesempatan untuk
Programme in
bayi ketika sedang Manajemen halusinasi mendiskusikan
dimandikan (6510): halusinasinya. Patients with
-klien tanpa 1. Tentukan care 6. Mendorong klien untuk Schizophrenia in
sengaja giver yang mengekspresikan Egypt. International
mendorong konsisten setiap perasaannya secara tepat
istrinya hingga hari 7. Memonitor kehadiran Journal of Psychiatry
jatuh. 2. Berikan klien halusinasi mengenai in Clinical Practice.
Ds: kesempatan untuk konten kekerasan atau
-klien mengatakan mendiskusikan yang membahayakan orang
mencari chip halusinasinya. lain.
implant di 3. Dorong klien untuk 8. Menggunakan bahasa yang
tangannya. mengekspresikan sederhana dan konkrit
perasaannya secra selama interaksi dengan
tepat pasien yang bermasalah
4. Monitor kehadiran dengan fungsi kognitifnya
halusinasi 9. Menggunakan alat bantu
mengenai konten mengingat dan tanda-tanda
kekerasan atau visual untuk membantu
yang pasien yang fungsi
membahayakan kognitifnya bermasalah
orang lain. 10. Mengajarkan pasien
Manajemen alam perasaan keterampilan membuat
(5330): keputusan, sesuai
1. Gunakan bahasa kebutuhan
yang sederhana dan
konkrit selama
interaksi dengan
pasien yang
bermasalah dengan
fungsi kognitifnya
2. Gunakan alat bantu
mengingat dan
tanda-tanda visual
 untuk membantu
pasien yang fungsi
kognitifnya
bermasalah
3. Ajarkan pasien
keterampilan
membuat
keputusan, sesuai
kebutuhan
D. TERAPI KELUARGA
a) Judul film: “BEAUTIFULL MIND”

b) Masalah keluarga: Resiko perilaku kekerasan terhadap orang lain b.d gangguan psikologis
dan waham

c) Terapi keluarga: Behavioural Family Psychoeducational Programme (BFPP)

d) Pengertian terapi keluarga: Behavioural Family Psychoeducational Programme (BFPP)

merupakan suatu program psikedukasi keluarga yang diadaptasi dari Budaya Perilaku
Keluarga pada Pasien dengan Skizofrenia

e) Indikasi terapi keluarga: keluarga dengan salah seorang anggota keluarga yang di diagnosa
skizofrenia

f) Kontraindikasi terapi keluarga: anggota keluarga yang menolak bila diberikan intervensi

g) Persiapan terapi keluarga :

 Perawat dapat menggali perasaan dan mengidentifikasi kelebihan juga kekurangan
agar dapat mengontrol diri juga rasa cemas sebelum berhadapan dengan pasien dan
keluarga ketika proses perawatan.
 Perawat dapat membaca rekam medik pasien dan mempelajari mengenai keluhan
pasien. Persiapan diri serta alat yang akan dibawa kepada pasien
 Perawat mempersiapkan lembaran fakta tentang skizofrenia dalam upaya untuk
meringkas dan menyoroti informasi, lembar catatan singkat dan lembar kerja rumah
untuk pelatihan keterampilan komunikasi, dan lembar catatan singkat dan lembar
pekerjaan rumah untuk pelatihan keterampilan pemecahan masalah

h) Prosedur terapi keluarga:

1. Prainteraksi:
 Mengumpulkan data tentang pasien (keluarga)
 Menyiapkan alat yang akan digunakan
 Menilai kesiapan diri perawat
 Membuat rencana pertemuan
2. Orientasi:
 Memberikan salam dan tersenyum pada Klien
 Melakukan validasi (kognitif, afektif, psikomotor), pada pertemuan Lanjutan
 Memperkenalkan nama Perawat
  Menanyakan nama panggilan kesukaan Klien (keluarga)
 Menjelaskan tanggung jawab Perawat - Klien (keluarga)
 Menjelaskan peran Perawat - Klien (keluarga)
 Menjelaskan kegiatan yang akan dilakukan
 Menjelaskan tujuan
 Menjelaskan waktu yang dibutuhkan untuk melakukan kegiatan
 Menjelaskan kerahasiaan
3. Kerja:
 BFPEP terdiri dari 14 sesi yang akan diberikan selama 6 bulan dengan frekuensi
sesi sekali seminggu untuk dua bulan pertama, kemudian sesi dua kali setiap
bulan selama dua bulan kedua, lalu satu sesi setiap tiga minggu dalam dua bulan
terakhir.
 Komponen-komponen sesi tersebut yaitu: (a) keterlibatan (1 sesi); (b) penilaian
(1 sesi); (c) psiko-edukasi (3 sesi), di mana pengasuh termotivasi untuk terlibat
dalam program dan belajar tentang tanda-tanda, gejala, etiologi dan tanda-tanda
kambuhnya skizofrenia; (d) pelatihan peningkatan komunikasi (4 sesi), di mana
para peserta belajar keterampilan untuk mendengarkan aktif, menyampaikan
umpan balik positif dan negatif, dan meminta perubahan dalam perilaku masing-
masing; (e) pelatihan keterampilan pemecahan masalah (4 sesi), di mana peserta
belajar untuk mengidentifikasi masalah keluarga tertentu dan untuk memilih dan
menerapkan satu atau lebih solusi; dan (f) penghentian (1 sesi).
 Setiap sesi berlangsung sekitar 45-60 menit tergantung pada kemajuan yang
dibuat oleh keluarga dalam mempelajari informasi atau keterampilan dari setiap
sesi.
 Setiap sesi kira-kira dibagi sebagai berikut:
1) 2–5 mnt: Sambutan awal, ulasan minggu ini, identifikasi area masalah baru.
2) 3–5 mnt: Ulasan gol anggota keluarga individu (dilakukan setelah sesi
pendidikan).
3) 5–15 menit: Tinjau pekerjaan rumah dan pertemuan keluarga
4) 15–30 menit: Lanjutkan bekerja pada pendidikan sebelumnya atau pelatihan
keterampilan atau mulai bekerja pada topik baru.
5) 5 menit: Menetapkan pekerjaan rumah.
6) 5–15 menit (opsional): Pemecahan masalah pada masalah penting yang
dibatasi yang diidentifikasi pada awal sesi.
 Membagikan lembaran terpisah kepada peserta selama setiap sesi. Ini termasuk:
1) Fakta tentang skizofrenia dalam upaya untuk meringkas dan menyoroti
informasi paling penting yang disampaikan selama sesi pendidikan.
 2) Catatan singkat dan lembar kerja rumah untuk pelatihan keterampilan
komunikasi.
3) Catatan singkat dan lembar pekerjaan rumah untuk pelatihan keterampilan
pemecahan masalah.
4. Terminasi:
 Menyimpulkan hasil percakapan (evaluasi proses & hasil )
 Memberikan reinforcement positif
 Merencanakan tindak lanjut dengan Klien (keluarga)
 Melakukan kontrak (waktu,tempat,topik)
 Mengakhiri tindakan dengan cara yang baik (ucapkan salam

i. Sumber referensi:
Khalil, A.H., El-Nahas, G., Ramy, H., Aziz, K.A., Elkholy, H., El-Gamry, R. 2018.
Impact of a Culturally Adapted Behavioural Family Psychoeducational Programme in
Patients with Schizophrenia in Egypt. International Journal of Psychiatry in Clinical
Practice.

j. Penulis:
 Afaf H. Khalil
 Gihan El-Nahas
 Hisham Ramy
 Karim Abdel Aziz
 Hussien El-kholy
 Reem El-Ghamry

E. CRITICAL APPRAISAL
1. Nama penulis
a) Afaf H. Khalil
b) Gihan El-Nahas
c) Hisham Ramy
d) Karim Abdel Aziz
e) Hussien El-kholy
f) Reem El-Ghamry

2. Judul Artikel
 Impact of a Culturally Adapted Behavioural Family Psychoeducational Programme in
Patients with Schizophrenia in Egypt

3. Jurnal
International Journal of Psychiatry in Clinical Practice

4. Tahun
2018

5. Tujuan
Untuk mempelajari pengaruh dari intervensi keluarga yang diadaptasi secara budaya dan
terstruktur pada tingkat keparahan gejala, sikap dan pengetahuan pengobatan, fungsi sosial
dan kualitas hidup pada pasien dengan skizofrenia.

6. Metodologi
30 responden dengan skizofrenia dipilih untuk menerima 14 sesi program psikoedukasi
keluarga yang disesuaikan budaya (Behavioural Family Psychoeducational Programme =
BFPEP). 30 subjek lainnya menerima perawatan standar seperti biasa (Standard
Treatment as Usual = STU) selama 6 bulan. Hasil sebelum dan sesudah intervensi dinilai
menggunakan Skala Sindrom Positif dan Negatif (Positive and Negative Syndrome Scale
= PANSS), Skala Inventaris Obat 10-item (DAI-10), Skala Kualitas Hidup (Quality of Life
Scale = QLS) dan Kuesioner Fungsi Sosial (Social Functioning Questionnaire = SFQ).

7. Hasil
Tidak ada perbedaan yang signifikan antara BFPEP dan STU pada awal pada semua
ukuran. Ada perbedaan yang signifikan (p <.05) antara skor sebelum dan sesudah
pengobatan untuk BFPEP pada semua ukuran, perbedaan yang signifikan (p <.05) antara
skor pra dan pasca perawatan untuk STU pada semua ukuran (mendukung pra -tingkat
perlakuan) dan perbedaan yang signifikan (p <.05) mendukung BFPEP atas STU pada
semua langkah pasca perawatan.
Hasil ini menunjukkan kelayakan dan efektivitas menerapkan intervensi psikoedukasi
terapi keluarga dalam pengaturan budaya yang berbeda, dengan modifikasi yang relatif
kecil. Ini mungkin berimplikasi pada pembuat kebijakan kesehatan mental untuk
menyediakan program seperti itu bagi pasien dan profesional kesehatan mental.

8. Pembahasan
Socio-demographic and clinical characteristics (Karakteristik sosio-demografi dan
klinis)
Karakteristik sosio-demografi dari kedua kelompok menunjukkan tidak ada perbedaan
yang signifikan secara statistik di antara mereka pada parameter apa pun; menunjukkan
bahwa sampel
dicocokkan untuk usia rata-rata, usia rata-rata onset penyakit, durasi rata-rata penyakit,
subtipe skizofrenia, jenis kelamin, pendidikan, status perkawinan dan pekerjaan.

Baseline assessment scores of patients with schizophrenia in case and control groups
(Skor penilaian awal pasien dengan skizofrenia di kelompok kasus dan kontrol)
Tidak ada perbedaan yang signifikan secara statistik (p> .05) antara kelompok kasus yang
menerima BFPEP dan kelompok kontrol yang menerima STU pada skor awal pada
PANSS, DAI-10, QLS dan SFQ atau pada salah satu subskala mereka yang menunjukkan
mereka dicocokkan berdasarkan tingkat keparahan gejala, sikap obat, kualitas hidup dan
fungsi sosial.

Effect of the BFPEP on clinical condition, drug attitude, quality of life and social
functioning (Pengaruh BFPEP pada kondisi klinis, sikap obat, kualitas kehidupan
dan fungsi sosial)
Ditemukan perbedaan yang signifikan secara statistik (p <.05) antara skor pra dan pasca
pengobatan pada pasien dengan skizofrenia pada kelompok kasus yang menerima BFPEP
pada PANSS, DAI-10, QLS dan SFQ dan semua subskala mereka, menunjukkan
keparahan gejala yang lebih sedikit, sikap obat yang lebih baik, kualitas hidup yang lebih
baik dan fungsi sosial yang lebih baik pada pasca perawatan. Untuk subjek yang tidak
menyelesaikan semua sesi, analisis intention-to-treat dilakukan menggunakan observasi
terakhir yang dilakukan (Last-Observation-Carried-Forward = LOCF)

Effect of standard treatment as usual (STU) on clinical condition, drug attitude,

quality of life and social functioning (Efek pengobatan standar seperti biasa (STU)
pada klinis kondisi, sikap obat, kualitas hidup dan fungsi sosial)
Ditemukan perbedaan yang signifikan secara statistik (p <.05) antara skor pra dan pasca
perawatan pada pasien dengan skizofrenia pada kelompok kontrol yang menerima STU
pada PANSS, DAI-10, QLS dan SFQ dan semua sub-skala mereka, menunjukkan
keparahan gejala lebih, sikap obat yang lebih buruk, kualitas hidup yang lebih buruk dan
fungsi sosial yang lebih buruk pada pasca perawatan pasca perawatan. Untuk subjek yang
tidak menyelesaikan semua sesi, analisis intention-to-treat dilakukan menggunakan LOCF
 Comparison between case and control groups regarding intervention outcome
measures (Perbandingan antara kelompok kasus dan kelompok kontrol terkait
pengukuran hasil intervensi)
Ditemukan perbedaan yang signifikan secara statistik (p <.05) antara pasien dengan
skizofrenia pada kelompok kasus yang menerima BFPEP dan pasien dengan skizofrenia
pada kelompok kontrol yang menerima STU mengenai pengukuran hasil intervensi pada
PANSS, DAI-10, QLS dan SFQ dan semua sub-skala mereka, menunjukkan keparahan
gejala yang lebih sedikit, sikap obat yang lebih baik, kualitas hidup yang lebih baik dan
lebih baik fungsi sosial pada pasca perawatan pada kelompok intervensi yang menerima
BFPEP dibandingkan dengan STU. Untuk subjek yang tidak menyelesaikan semua sesi,
analisis intention-to-treat dilakukan menggunakan LOCF.

9. Kesimpulan
Berdasarkan penelitian tersebut dapat disimpulkan bahwa penerapan program
psikoedukasi keluarga memiliki dampak positif pada pasien dengan skizofrenia
sehubungan dengan perbaikan dalam simtomatologi, kepatuhan terhadap pengobatan,
kualitas hidup pasien dan fungsi sosial.
Dalam penelitian tersebut, penulis mencakup berbagai ukuran hasil dari banyak
penelitian sebelumnya. Temuan ini menunjukkan bahwa menghabiskan waktu dan usaha
untuk menyediakan program psikoedukasi keluarga untuk pasien skizofrenia dan keluarga
mereka berharga. Oleh karena itu, setiap pendekatan perawatan komprehensif untuk
pasien dengan skizofrenia harus memasukkan psikoedukasi keluarga sebagai salah satu
komponen utamanya. Ini akan meningkatkan pengetahuan pasien tentang skizofrenia dan
akan memiliki dampak positif pada sikap mereka terhadap penyakit mereka. Ini juga akan
meningkatkan sosial berfungsi, kualitas hidup dan kondisi klinis pasien.
 International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Impact of a culturally adapted behavioural

family psychoeducational programme in
patients with schizophrenia in Egypt

Afaf H. Khalil, Gihan ELNahas, Hisham Ramy, Karim Abdel

Aziz, Hussien Elkholy & Reem El-Ghamry

To cite this article: Afaf H. Khalil, Gihan ELNahas, Hisham Ramy, Karim
Abdel Aziz,
Hussien Elkholy & Reem El-Ghamry (2018): Impact of a culturally adapted
behavioural family psychoeducational programme in patients with
schizophrenia in Egypt, International Journal of Psychiatry in Clinical Practice,
DOI: 10.1080/13651501.2018.1480786

To link to this article:

https://doi.org/10.1080/13651501.2018.1480786

Published online: 17 Jul 2018.

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INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE

https://doi.org/10.1080/13651501.2018.1480786

ORIGINAL ARTICLE

Impact of a culturally adapted behavioural family psychoeducational programme

in patients with schizophrenia in Egypt

Afaf H. Khalila, Gihan ELNahasa, Hisham Ramya, Karim Abdel Azizb, Hussien Elkholya and Reem
El-Ghamrya

a b
Department of Psychiatry, Ain Shams University, Cairo, Egypt; Department of Psychiatry, College of Medicine and Health
Sciences, United Arab Emirates University, Al-Ain, UAE

ABSTRACT ARTICLE HISTORY

Objective: To study the effect of a culturally adapted, structured family intervention on symptom Received 22 January 2018
severity, medication attitudes and knowledge, social functioning and quality of life in patients with Revised 23 April 2018
schizophrenia. Methods: Thirty subjects with schizophrenia were selected to receive 14 sessions of a Accepted 22 May 2018
culturally adapted behavioural family psychoeducational programme (BFPEP). Another 30 subjects
received standard treat-ment as usual (STU) for 6 months. Pre- and post-intervention outcomes were
assessed using the Positive and Negative Syndrome Scale (PANSS), Drug Attitude Inventory 10-item
KEYWORDS
scale (DAI-10), Quality of Life Scale (QLS) and Social Functioning Questionnaire (SFQ).

Schizophrenia; family
Results: There was a no significant difference between BFPEP and STU at baseline on all measures. therapy; psychoeduca-
There was a significant difference (p < .05) between pre- and post-treatment scores for BFPEP on all tion; Egypt
measures, a significant difference (p < .05) between pre- and post-treatment scores for STU on all
measures (favouring pre-treatment scores) and a significant difference (p < .05) favouring BFPEP
over STU on all measures post-treatment.

Conclusions: These results demonstrate the feasibility and effectiveness of implementing family
therapy psychoeducational interventions in different cultural settings, with relatively minor
modifications. This may have implications for mental health policy makers to make available such
programmes for patients and mental health professionals.

residential resources, families of patients with schizophrenia have

had to be the substitute and for this reason, the viability of patients’
care by families has become a challenge (Caqueo-Urızar, Rus-
Calafell, Urzua, Escudero, & Gutierrez-Maldonado, 2015). This is
clear in many developing countries such as Egypt where patients
with schizophrenia do not generally receive welfare bene-fits, or
medical insurance and thus the costs of therapy are almost
exclusively covered by their families (Assad et al., 2015). This pla-
Introduction ces a considerable burden on families and inversely affects patients
clinical outcomes (El-Shafei, 2002).

Family interventions have been demonstrated to be effective for

Although pharmacological treatment remains the cornerstone for
patients with schizophrenia but their implementation in clinical
the management of psychotic disorders, substantial additional
settings, as well as in treatment protocols, have not yet been fully
benefits have been reported when optimal pharmacotherapy has
achieved. In the face of a scarcity of therapeutic, occupational and
been integrated with family-based treatments (Dixon et al., 2010).
The driving force behind family interventions is the supposition that
social environments can influence the course of the illness for better
or worse. If social factors are responsible for precipitat-ing relapses,
then they can, at least in theory, be identified and modified to
reduce the risk of relapse (Barrowclough & Tarrier, 1997). In
addition to treatment interventions directed towards decreasing
symptoms, an individual’s recovery plan must include rehabilitative
services directed towards enhancing adaptive skills
and social support mobilisation aimed at optimizing function and
quality of life. The ultimate clinical objective in the treatment of
schizophrenia is to enable the affected individual to lead a max-
imally productive and personally meaningful life (Tandon,
Targum, Nasrallah & Ross, 2006).

There is a well-established evidence-base detailing the

effect-iveness of family interventions in terms of reducing
relapse rates and symptom severity of schizophrenia (Dyck et
al., 2000; Hogarty et al., 1986; Kulhara, Chakrabarti, Avasthi,
Sharma & Sharma, 2009; Leff et al., 1989; Magliano et al.,
2006; McFarlane, Link, Dushay, Marchal, & Crilly, 1995; Nasr &
Kausar, 2009; Rummel-Kluge & Kissling, 2008a).

A 2010 Cochrane review confirmed that family interventions can

significantly reduce levels of relapse, hospital admissions and high
EE, leading to measurable improvements in patient social
functioning and treatment engagement with a reported reduction in
relapse at 12 months, compared with standard treatment (Pharoah,
Mari, Rathbone, & Wong, 2010). Evidence also shows that these
interventions have proven efficacy during the early ill-ness phases
(Bird et al., 2010) and that positive effects can be enduring
(Sellwood, Wittkowski, Tarrier, & Barrowclough, 2007), with one
study suggesting continued efficacy for 14 years post-intervention
(Ran, Chan, Ng, Guo, & Xiang, 2015). In addition, there is evidence
that family interventions have proven real-world effectiveness
(Ruggeri et al., 2015) with economic analysis confirm-ing their cost-
effectiveness (Christenson, Crane, Bell, Beer, & Hillin, 2014) and
evidence showing that they are acceptable to families, with
perceived benefits including improved communication

CONTACT Karim Abdel Aziz kabdelaziz@uaeu.ac.ae Department of Psychiatry, United Arab Emirates University, PO Box 17666, Al-Ain, UAE

2018 Informa UK Limited, trading as Taylor & Francis Group

 intervals, 0.80 power of the study and alpha error of 0.05. Sample
2 A. H. KHALIL ET AL.
size was calculated to include at least 20 subjects in each arm of
the study. The study was approved by the Research and Ethics
Committee of the Institute of Psychiatry, Ain Shams University,
Cairo, Egypt.
between family members and problem-solving skills (Nilsen,
Frich, Friis, Norheim, & Rossberg, 2016).
Initially, 114 participants were approached to participate in
the study. After being selected and giving consent, 54 subjects
However, a recent review of family psychoeducation for
either failed to show up for their first assessment (despite being
schizo-phrenia concluded that although there was a reduction in
sched-uled and reminded of the date and time) or came to the
the risk of relapse, effectiveness did not seem to be maintained
initial assessment but declined to continue in the programme
at follow-up. Hospital admission and rehospitalisation seemed to
after knowing the number and schedule of sessions which they
be less influenced by family psychoeducation, and the authors
could find no reproducible effects on medication compliance.
They con-cluded that overall, the quality of evidence for the
effectiveness of family psychoeducation in schizophrenia was
poor (Petretto et al., 2017).

Despite the mostly positive evidence for family therapy, it is

yet to be considered an essential component of routine manage-
ment for patients with schizophrenia in many developing coun-
tries, including Egypt. It remains difficult to implement, due to
variable socio-cultural factors and rigid care system structures,
and this may influence the acceptance of such forms of
treatment (Glynn et al., 2002).

Few studies in Egypt have looked at the effect of family-based

interventions in patients with schizophrenia. A previous study was
based on group educational interventions and demonstrated
reduced relapse rates and improved quality of life (Abolmagd et al.,
2004). Therefore, there is a need for further research into the
efficacy of culturally-appropriate family-based interventions in
schizophrenia. In this study, our objective was to adapt a behav-
ioural family psychoeducational programme (BFPEP) where, in
addition to psychoeducational sessions, we provided interactive
communication skills training sessions and interactive problem-
solving skill sessions. We also incorporated cultural and religious
values as these have previously been demonstrated to be associ-
ated with positive treatment outcomes (Naeem et al., 2015). We
hypothesised that compared to treatment, as usual, structured
family interventions would help reduce symptoms, improve medi-
cation attitudes and knowledge, improve social functioning and
improve quality of life of patients with schizophrenia.

Materials and methods

Participants

Sixty subjects were recruited from the psychiatric outpatient clinic of

the Institute of Psychiatry, Ain Shams University Hospitals, Cairo,
Egypt over a 9-month period. We included male and female
subjects between the ages of 18 and 65, with a DSM-IV diagnosis
of schizophrenia after improvement from an acute episode of the
illness. We excluded subjects with comorbid psychiatric disorders
and those who were unable to understand the educational mater-ial
presented in the programme. To calculate the sample size, we used
a computerised statistics programme called Epi info version 3.4.3
(CDC, Atlanta, GA) (www.cdc.gov/epiinfo) and we also referred to
results from previous studies about average relapse rates among
schizophrenic patients whose received family therapy (Mueser &
Glynn, 1998). All calculations were performed at 95% confidence
 positive total score means a posi-tive subjective response. A
negative total score means a negative subjective response. In
our study, we used the Arabic version by El-Ghamry (2010).

perceived as excessive. Therefore, those who were selected
and assessed initially to participate in the study were 60
subjects. Participants were divided into two groups. A control
group (30 subjects) was randomised to receive standard
treatment as usual (STU) and a case group of 30 subjects was
randomised to receive a structured BFPEP.
Procedures
4 – Quality of Life Scale (QLS) (Heinrichs, Hanlon, & Carpenter,
1984): The QLS is a clinician-administered, 21-item scale derived
from a semi-structured interview which provides information on
symptoms and functioning during the preceding 4 weeks. Each item
is rated on a 7-point scale with high scores reflecting normal or
unimpaired functioning, and low scores (0 and 1) reflecting impaired
functioning. The QLS was designed specifically to address the more
insidious deficit symptoms of schizophrenia (e.g., anhedonia,
emotional interaction, socio-sexual relations, social activity, work
functioning). Several of the items require descriptions of
intrapsychic states or experiences to which the

Random sampling

Sampling was done by matched random sampling which is a

method of assigning participants to groups in which pairs of par-
ticipants are first matched on some criteria and then individually
assigned randomly to groups (i.e., each subject is selected and then
matched to another subject into pairs and then within each pair the
subjects are randomly assigned to either the case or the control
group, two samples in which the members are clearly paired or
matched). Out of the 60 subjects who participated in the
programme, 4 subjects from the case group and 6 subjects from the
control group missed their regular sessions. Therefore, the
participants who completed all the sessions were 50 subjects.

Tools

Data was collected for each subject’s demographic and clinical

characteristics. The following assessment tools were used:

1 – Structured Clinical Interview for DSM-IV (SCID-I) (research

version) (First, Gibbon, Spitzer, Williams, & Benjamin, 1995):
The SCID-I is a clinician administrated, semi-structured
diagnostic inter-view that was developed to confirm psychiatric
diagnoses accord-ing to DSM-IV. This was used to ascertain the
diagnosis of schizophrenia. In our study, we used the Arabic
version of the SCID-I (El-Missiry, 2003).

2 – Positive and Negative Syndrome Scale (PANSS) (Kay,

Fiszbein, & Opler, 1987): This is a scale used for measuring
symp-tom severity in patients with schizophrenia. The patient is
rated from 1 to 7 on 30 different symptoms: 7 items for positive
(P) symptoms; 7 items for negative (N) symptoms; and 16 items
for general psychopathology symptoms. Scores are calculated
for the individual domains (P, N and general psychopathology
scores) as well as a total PANSS score.

3 – Drug Attitude Inventory, 10-item scale (DAI-10) (Hogan,

Awad, & Eastwood, 1983): The DAI-10 is a self-report scale
devel-oped to measure patient’s subjective responses to
medications as well as values and attitudes towards illness and
health. The items in the scale are presented as self-report
statements with which the patient agrees or disagrees. Each
response is scored as þ1 if correct or 1 if incorrect. The final
score is the grand total of the positive and negative points. A
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 3

patient alone has direct access and about which others can only Short notes and home worksheets for the communication

make inferences (e.g., work satisfaction, sense of purpose, curios- skills training.

ity, anhedonia). In our study, we used the Arabic version by El- Short notes and homework sheets for the problem-solving

The study proper was preceded by a pilot phase of three months, to

adapt the family intervention programme to the Egyptian cul-ture.
This was conducted on 20 subjects who were not included in the
main study. The aim of this phase was to test the applic-ability and
linguistic simplicity of the tools and educational mate-rials and to
make necessary adaptations to the Egyptian culture. The most
noticeable cultural adaptations were:

Ghamry (2010). skills training.

5 – Social Functioning Questionnaire (SFQ) (Clifford, 1987): This

is a 41-item, observer-rated tool that assesses the patient’s level

Adaptation of the interventional programme

of adaptive functioning in the domains of self-care, domestic skills,

community skills, social skills and responsibility. Items are scored

on a scale from 1 to 4 with 1 indicating poor ability and 4 indicat-

ing high ability. A mean score is given for overall and component

skill levels. In our study, we used the Arabic version by Hussein,

El-Shafei, & Okasha (2006).

Baltimore, MA and were taught to administer the sessions accord-

ing to the manual of family therapy by Mueser & Glynn (1998). The
role of the researchers was to coordinate and assist family members
Model of BFPEP sessions
in learning new information and coping skills.

The BFPEP sessions were held at the Institute of Psychiatry, Each session lasted about 45–60 min depending on the pro-
Ain Shams University. Each session was attended by the patient gress made by the family in learning the information or skills
and the primary caregiver (one relative per patient). The from each session.
sessions were administered in 14 sessions over 6 months with a
frequency of once weekly sessions for the first two months, then
twice monthly sessions for the second two months, then one
Each session was approximately subdivided as follows:
session every three weeks in the last two months.

The components of the sessions were delivered in the follow- 2–5 min: Initial greetings, review of the week, identification
ing modules: (a) engagement (1 session); (b) assessment (1 of new problem areas.
ses-sion); (c) psycho-education (3 sessions), in which
caregivers were motivated to engage in the programme and
learned about the signs, symptoms, aetiology and relapse signs 3–5 min: Review of individual family members’ goals (con-
of schizophrenia; (d) communication enhancement training (4 ducted after educational sessions).
sessions), in which par-ticipants learnt skills for active listening,
5–15 min: Review homework and family meeting.
delivering positive and negative feedback, and requesting
changes in each other’s behav-iours; (e) problem-solving skills
training (4 sessions), in which par-ticipants learned to identify 15–30 min: Continue work on previous educational or skills-
specific family problems and to choose and implement one or training topic or begin work on new topic.
more solutions; and (f) termination (1 session).

5 min: Assign homework.

The researchers administering the sessions were trained in
behavioural family therapy (BFT) for Psychiatric disorders through a
training workshop held at the Baltimore VA Medical Centre,
 5–15 min (optional): Problem-solve on important, circum-
scribed issues identified at the beginning of session.
Separate sheets were distributed to the attendees during
each session. These included:
1. The programme although written in the classical Arabic lan-
guage was delivered in a much simpler spoken language
using the Egyptian-Arabic dialect to make it easily under-
stood by lay people. Also, folk stories and examples
relevant from Egyptian culture were used for clarification.

2. The educational component was adapted from the psycho-

Facts about schizophrenia in an attempt to summarise and
highlight the most critical information delivered during the
educational sessions.
3.
educational programme by El-Shafei (2002) which had
previ-ously been carried out in an Egyptian population and
so this was used unchanged.
Separate Arabic information leaflets were distributed to the
participants during each session, which included facts
about schizophrenia, such as the signs, symptoms,
aetiology and relapse signs of the illness, high expressed
emotion (EE) fami-lies and assignments for problem-solving
and communication skills training.

4. Shorter family therapy programmes were adapted for only 6

months, not the 9 months’ duration of the original pro-
gramme by Mueser & Glynn (1998). Through discussions
with the patients and their families, it was speculated that
they would not comply with a 9-month programme due to
the practical and financial concerns that they raised e.g.,
transpor-tation time and fees, work commitments and
competing demands which were thought may negatively
influence adherence and impair adequate attendance.

5. Families preferred individual rather than group sessions

mainly because relatives reported that they would feel
uncomfortable about revealing the details of the psychiatric
illness of the family members in groups.

6. In this study, 12 patients had seen a spiritual/faith healer

prior to seeing a psychiatrist. Thus, a major part of the
educa-tional sessions of the BFT programme focused on
educating patients and their families about the biological
basis of the illness: explaining the disturbance of the
neurotransmitters, genetic and environmental theories and
the effect of medica-tions. The research team, therefore,
spent 2 sessions for this purpose, instead of one session as
outlined in the original BFT programme.

Standard treatment as usual (STU)

The STU consisted of monthly medical consultations and

advice. It also included two brief family educational sessions
(each 90 min) that focused on the management of the
immediate family con-flicts. They consisted of giving basic
information about schizophre-nia and its outcome and treatment
options which aimed mostly at improving knowledge but did not
focus on changing attitudes or developing problem-solving skills.
4 A. H. KHALIL ET AL.

Intervention outcome measures assessment Baseline assessment scores of patients with schizophrenia in

case and control groups

Throughout the study, subjects were rated twice: when they first

enrolled in the study (baseline scores); and then immediately after There was no statistically significant difference (p >.05) between

the intervention programme was completed, usually after the ter- the case group receiving the BFPEP and control group receiving

mination session (end of study scores). Two trained raters, who STU on baseline scores on the PANSS, DAI-10, QLS and SFQ or on

were blinded to patients’ type of intervention, were involved in any of their subscales indicating they were matched on baseline

scoring the measures and were independent from the delivery of symptom severity, drug attitude, quality of life and social function-

ing (Table 2).

the therapy to either groups.

Statistical methods

Results were recorded and analysed using the statistical package

Table 2. Comparison between patients with schizophrenia in both cases and

of social sciences SPSS 15th version (2007) (SPSS, Chicago, IL, control groups regarding baseline assessment scores.

USA). The results were tabulated, grouped and statistically ana- Cases Controls
t-test
lysed using the following tests: Mean (M) ± standard deviation (SD) (n¼ 30) (n¼ 30)

for quantitative data and frequency with percentage (for qualita- Baseline assessment scores Mean ± SD Mean ± SD t df p Value

tive data). Chi-square test was used for the comparison of cat- PANSS total score 42.1 ± 7.6 44.3 ± 7.4 1.1 58 .266

PANSS P score 9.0 ± 2.2 10.3 ± 3.4 1.7 58 .083

egorical variables. Continuous normally distributed variables were
PANSS N score 11.3 ± 3.7 11.3 ± 4.1 0.1 58 .947

compared by independent sample t-test. An intention to treat PANSS G score 18.1 ± 3.2 19.1 ± 2.8 1.3 58 .206

analysis was used to minimise the drop out bias. Cohen’s Kappa DAI-10 score 1.07 ± 3.9 0.67 ± 3.1 0.4 58 .664

was used to measure the inter-rater agreement for the translated QLS total score 59.4 ± 10.5 53.7 ± 17.1 1.6 58 .126

study tools. A statistical level of significance was set at a Interpersonal relation 22.1 ± 4.4 20.1 ± 9.8 1.0 58 .316

Instrumental role 11.6 ± 4.5 10.1 ± 4.1 1.4 58 .172

p value .05. Intra-psychic foundations 19.9 ± 4.8 18.2 ± 5.7 1.3 58 .211

Common objects and activities 5.7 ± 1.2 5.3 ± 1.5 1.3 58 .215

SFQ total score 11.4 ± 10.4 10.7 ± 20.2 1.6 58 .106

Results Self-care 24.1 ± 3.7 22.0 ± 5.1 1.8 58 .076

Domestic skills 20.2 ± 4.9 18.7 ± 4.1 1.3 58 .215

Socio-demographic and clinical characteristics Community skills 25.9 ± 2.9 24.6 ± 4.8 1.3 58 .191

Social skills 19.9 ± 3.7 18.8 ± 4.9 0.9 58 .322

The socio-demographic characteristics of the two groups (sum-

Responsibility 24.1 ± 4.2 23.3 ± 4.3 0.7 58 .486

marised in Table 1) showed no statistically significant difference N: number; SD; standard deviation; df: degree of freedom; t: t-test;

between them on any parameters; indicating that the samples PANSS: Positive and Negative Syndrome Scale; p Score: Positive Symptoms sub-
 scale; n Score: Negative Symptoms subscale; G Score: General Psychopathology
were matched for mean age, mean age of onset of the illness,

subscale; DAI-10: Drug Attitude Inventory, 10-item scale; QLS: Quality of Life
mean duration of the illness, subtype of schizophrenia, gender,
Questionnaire; SFQ: Social Functioning Questionnaire.

education, marital status and occupation.

Table 1. Socio-demographic and clinical profiles of cases and controls.

Test

Cases Controls
t-test
(n¼ 30) (n¼ 30)

Mean ± SD Mean ± SD t df p Value

Age (in years) 33.1 ± 9.3 35.2 ± 10.9 0.81 58 .420

Age of onset (in years) 24.6 ± 7.7 26.0 ± 8.8 0.66 58 .513

Duration of Illness (in years) 8.3 ± 6.9 9.4 ± 7.3 0.62 58 .540

Chi-square

2
n % n % v df

Schizophrenia Subtype

Paranoid 14 47 8 27 2.6 2 .268

Disorganised 4 13 6 20

Undifferentiated 12 40 16 53

Gender

Male 22 73 20 67 0.32 1 .573

Female 8 27 10 33

Education

Ill./Prim/Prep 4 13 8 27 1.7 1 .197

Sec/Tech/Uni 26 87 22 73

Marital Status

Single 24 80 20 67 2.46 2 .293

Sep./div. 2 7 6 20

Married 4 13 4 13

Occupation

Employed 19 63 14 47 1.684 1 .194

Unemployed 11 37 16 53

2
n: number; SD: standard deviation; df: degree of freedom; t: t-test; v : chi-square; Ill.: illiterate; Prim.: primary school, Prep.: preparatory
education; Sec.: secondary education; Tech.: technical education, Uni.: university education; Sep.: Separated; Div.: divorced.
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 5

Effect of the BFPEP on clinical condition, drug attitude, quality Effect of standard treatment as usual (STU) on clinical
of life and social functioning condition, drug attitude, quality of life and social functioning

We found a statistically significant difference (p <.05) between pre-
and post-treatment scores in patients with schizophrenia in the case
group receiving the BFPEP on the PANSS, DAI-10, QLS and SFQ
and all of their subscales, indicating less symptom sever-ity, better
drug attitude, better quality of life and better social functioning at
post-treatment. For subjects who did not complete all sessions, an
intention-to-treat analysis was carried out using last-observation-
carried-forward (LOCF) (Table 3).
We found a statistically significant difference (p <.05) between
pre- and post-treatment scores in patients with schizophrenia in
the control group receiving STU on the PANSS, DAI-10, QLS
and SFQ and all of their subscales, indicating more symptom
severity, poorer drug attitude, poorer quality of life and poorer
social func-tioning at post-treatment at post-treatment. For
subjects who did not complete all sessions, an intention-to-treat
analysis was car-ried out using LOCF (Table 4).

Table 3. Comparison between baseline assessment scores and outcome measures of patients
a
with schizo-phrenia in case group .

Paired t-test
Baseline assessment scores Outcome measures

Mean ± SD Mean ± SD t df p Value

PANSS total score 42.1 ± 7.6 37.7± 4.3 5.1 29 <.001

PANSS P score 9.0 ± 2.2 8.3± 1.7 2.9 29 .008

PANSS N score 11.3 ± 3.7 9.2± 2.3 4.8 29 <.001

PANSS G score 18.1 ± 3.2 17.0± 1.8 3.5 29 .002

DAI-10 score 1.07 ± 3.9 4.5± 3.1 4.7 29 <.001

QLS total score 59.4 ± 10.5 72.1± 16.9 6.4 29 <.001

Interpersonal relation 22.1 ± 4.4 26.5± 5.8 5.9 29 <.001

Instrumental role 11.60 ± 4.5 14.2± 5.1 5.5 29 <.001

Intra-psychic foundations 19.9 ± 4.8 24.9± 6.8 5.9 29 <.001

Common objects and activities 5.7 ± 1.2 6.4± 1.6 3.6 29 <.001

SFQ total score 11.4 ± 10.4 12.9± 12.4 7.9 29 <.001

Self-care 24.1 ± 3.7 28.1± 4.4 5.7 29 <.001

Domestic skills 20.2 ± 4.9 22.8± 3.9 5.2 29 <.001

Community skills 25.9 ± 2.9 27.9± 3.1 29 <.001

 5.1

Social skills 19.9 ± 3.7 23.5± 3.8 5.1 29 <.001

Responsibility 24.1 ± 4.2 27.4± 3.5 5.6 29 <.001

a
Intention-to-treat analysis using last-observation-carried-forward was carried out for subjects
who did not complete all sessions.

p statistically significant.

SD: standard deviation; df: degree of freedom; t: t-test; PANSS: Positive and Negative Syndrome Scale; p

Score: Positive Symptoms subscale; n Score: Negative Symptoms subscale; G Score: General Psychopathology

subscale; DAI-10: Drug Attitude Inventory, 10-item scale; QLS: Quality of Life Questionnaire; SFQ: Social

Functioning Questionnaire; LOCF: last observation carried forward.

Table 4. Comparison between baseline assessment scores and outcome measures of patients
a
with schizo-phrenia in control group .

Paired t-test
Baseline assessment scores Outcome measures

Mean ± SD Mean ± SD t df p value

PANSS total score 44.3± 7.4 53.1 ± 13.1 4.5 29 <.001

PANSS P score 10.3± 3.4 15.9 ± 6.4 4.5 29 <.001

PANSS N score 11.3± 4.1 13.3 ± 5.5 2.9 29 .006

PANSS G score 19.1± 2.8 20.1 ± 3.7 2.4 29 .024

DAI-10 score 0.67± 3.1 0.8 ± 3.4 2.4 29 .021

QLS total score 53.7± 17.1 43.7 ± 21.1 5.9 29 <.001

Interpersonal relation 20.1± 9.8 18.3 ± 10.5 2.7 29 .012

Instrumental role 10.1± 4.1 6.7 ± 5.8 6.0 29 <.001

Intra-psychic foundations 18.2± 5.7 14.5 ± 6.7 6.2 29 <.001

Common objects and activities 5.3± 1.5 4.1 ± 1.9 7.2 29 <.001

SFQ total score 10.7± 20.2 9.66 ± 24.0 5.0 29 <.001

Self-care 22.0± 5.1 19.2 ± 5.6 5.7 29 <.001

Domestic skills 18.7± 4.1 17.6 ± 4.0 4.7 29 <.001

Community skills 24.6± 4.8 22.7 ± 5.8 3.4 29 .002

Social skills 18.8± 4.9 16.5 ± 5.9 4.5 29 <.001

Responsibility 23.3± 4.3 20.6 ± 5.2 4.9 29 <.001

a
Intention-to-treat analysis using last-observation-carried-forward was carried out for subjects
who did not complete all sessions.

p statistically significant.

SD: standard deviation; df: degree of freedom; t: t-test; PANSS: Positive and Negative Syndrome Scale; p

Score: Positive Symptoms subscale; n Score: Negative Symptoms subscale; G Score: General Psychopathology

subscale; DAI-10: Drug Attitude Inventory, 10-item scale; QLS: Quality of Life Questionnaire; SFQ: Social

Functioning Questionnaire; LOCF: last observation carried forward.

6 A. H. KHALIL ET AL. PANSS, DAI-10, QLS and SFQ and all of their subscales,
indicating less symp-tom severity, better drug attitude, better
Table 5. Comparison between case and control groups regarding out- quality of life and better social functioning at post-treatment in
the intervention group receiving the BFPEP compared to STU.
a
come measures . For subjects who did not complete all sessions, an intention-to-
treat analysis was carried out using LOCF (Table 5).
Cases Controls
t-test
(n ¼ 30) (n ¼ 30)
Discussion
Outcome measures Mean ± SD Mean ± SD t df p value

PANSS total score 37.7 ± 4.3 53.1 ± 13.1 6.1 58 <.001

To the best our knowledge, this study is the first Egyptian study to
PANSS P score 8.3 ± 1.7 15.9 ± 6.4 6.2 58 <.001 investigate the effectiveness of incorporating interactive com-
munication skills training sessions and interactive problem-solving
PANSS N score 9.2 ± 2.3 13.3 ± 5.5 3.8 58 <.001 skills sessions (in addition to educational sessions) as part of
behavioural family interventions in patients with schizophrenia.
PANSS G score 17.0 ± 1.8 20.1 ± 3.7 4.1 58 <.001

DAI-10 score 4.5 ± 3.1 0.8 ± 3.4 6.3 58 <.001

QLS total score 72.1 ± 16.9 43.7 ± 21.1 5.7 58 <.001 Effect of BFPEP on clinical outcomes
Interpersonal relation 26.5 ± 5.8 18.3 ± 10.5 3.7 58 <.001

Instrumental role 14.2 ± 5.1 6.7 ± 5.8 5.4 58 <.001 Our study showed a significant improvement in total and all sub-
scale scores of the PANSS in patients receiving BFPEP when com-
Intra-psychic foundations 24.9 ± 6.8 14.5 ± 6.7 5.9 58 <.001
paring pre-and post-treatment scores. Kulhara et al. (2009) found
Common objects and activities 6.4 ± 1.6 4.1 ± 1.9 5.0 58 <.001 significant reductions in the severity of symptoms on all subscales
of the PANSS in a patient group receiving a structured psychoedu-
SFQ total score 12.9 ± 12.4 9.66 ± 24.0 6.7 58 <.001 cational programme compared to baseline and also compared to a
control group receiving treatment as usual.
Self-care 28.1 ± 4.4 19.2 ± 5.6 6.8 58 <.001

Domestic skills 22.8 ± 3.9 17.6 ± 4.0 5.0 58 <.001 Merinder et al. (1999) found that the schizophrenia sub-score of
the Brief Psychiatric Rating Scale was reduced in a family inter-
Community skills 27.9 ± 3.1 22.7 ± 5.8 4.3 58 <.001
vention group at 12-month follow-up compared with the control
Social skills 23.5 ± 3.8 16.5 ± 5.9 5.5 58 <.001 group. Similarly, a meta-analysis by Claxton, Onwumere, &

Responsibility 27.4 ± 3.5 20.6 ± 5.2 5.9 58 <.001

a
Intention-to-treat analysis using last-observation-carried-forward was
carried out for subjects who did not complete all sessions.

p statistically significant.

N: number; SD: standard deviation; df: degree of freedom; t: t-test; PANSS:

Positive and Negative Syndrome Scale; p Score: Positive Symptoms sub-
scale; n Score: Negative Symptoms subscale; G Score: General
Psychopathology subscale; DAI-10: Drug Attitude Inventory, 10-item scale;
QLS: Quality of Life Questionnaire; SFQ: Social Functioning Questionnaire;
LOCF: last observation car-ried forward.

Comparison between case and control groups

regarding intervention outcome measures

We found a statistically significant difference (p <.05) between

patients with schizophrenia in the case group receiving the
BFPEP and patients with schizophrenia in the control group
receiving STU regarding intervention outcome measures on the
 24 months. Furthermore, Lecompte and Pelc (1996) found that
there is a sig-nificant reduction in the duration of hospitalisation in
the year fol-lowing a cognitive behavioural programme aimed at
improving compliance. Also, adequate adherence was related to
Fornells-Ambrojo (2017) found a significant reduction in better over-all functioning, less psychopathology and fewer
psychotic symptoms in patients with first-episode psychosis hospitalisations (Garcıa Cabeza, Sanchez Dıaz, Sanz Amador,
receiving family interventions (Claxton et al., 2017). Reduction in Gutierrez Rodrıguez,
the severity of symptoms of schizophrenia subjects receiving
psychoeducational interventions was also reported in several
other studies (Bradley et al., 2006; Chan, Yip, Tso, Cheng &
Tam, 2009; Li & Arthur, 2005; Magliano et al., 2006; Stanley &
Shwetha, 2006). In Egypt, the study by Hussein et al. (2006)
found significant improvements on the total PANSS scores but
this change was the result of a signifi-cant improvement only on
the Negative symptoms scale with no significant difference
between cases or controls on the other sub-scales of the
PANSS being reported. Training in communication skills may
have had a positive effect on improving nega-tive symptoms.

This improvement in symptoms in the treatment group can be

explained by the fact that BFPEP increases patient compliance to
treatment and it is generally believed that people with schizo-
phrenia that regularly take prescribed antipsychotic drugs, show a
faster and more complete remission, and a lower risk of relapse
(Fenton, Blyler, & Heinssen, 1997). A 2010 Cochrane review also
confirmed that family interventions significantly reduced levels of
relapse and hospital admissions (Pharoah et al., 2010).

Effects of the BFPEP on compliance and attitude to medication

In our study, there was a significant difference in compliance

and attitude towards psychotropic medications in favour of
patients receiving BFPEP both when comparing pre- and post-
treatment and when comparing to STU at post-treatment. This
shows that attitudes of patients towards medications and
consequently their compliance to medications can be increased
by providing the patients and their caregivers with the sufficient
information about the medications, their doses, their possible
side effects and how to deal with them. Also, patient compliance
can be increased by highlighting the course of the schizophrenic
illness especially with regards to the liability for relapses and the
importance of taking the medications to avoid this.

Our findings were in line with the 2010 Cochrane review that
showed that family interventions lead to measurable improve-ments
in treatment engagement (Pharoah et al., 2010). Similarly, Aguglia,
Pascolo-Fabrici, Bertossi, & Bassi (2007) found that an intervention
group that was treated over 12 months with drug therapy and
psychoeducation for patients and their families showed a significant
improvement in compliance to medication after 12 months of the
intervention. Kemp and David (1996) using compliance therapy, a
combination of cognitive approaches and motivational interviewing,
found sustained gains in medication compliance over 18 months
after hospital discharge and better insight and attitudes towards
medication. Chan et al. (2009) assessed adherence to medication
immediately after, then at 3, 6 and 12 months after the intervention.
There were significant treat-ment effects till 6 months but after 12
months there was no sig-nificant effect and they concluded that the
effects might not be sustained 12 months after the intervention.
Similarly, Carra, Montomoli, Clerici, & Cazzullo (2007) found that
compliance was greater at 12 months in a more intensive
behavioural manage-ment group compared to a control group
receiving treatment as usual but that treatment benefits declined at
 Contrary to our findings, El-Shafei (2002) tried to find out the
effect of education of relatives on social functioning of patients in an
intervention group. The SFQ was used to assess the different
dimensions of social performance in patients. No statistically sig-
& Gonzalez de Chavez, 1999). Hussein et al. (2006) aimed at nificant improvement was detected in the social functioning of
improving attitudes among patients of the case group through patients in the case group as compared to the controls over time
cognitive approaches, and found a significant improvement as both on total SFQ or its subscales. This difference in results may be
measured by the DAI over 24 months. This was also demonstrated because their study used a short-term intervention educational
by Pitschel-Walz, Leucht, B€auml, Kissling, & Engel (2001), where
patients attending psychoeducational groups showed better com-
pliance than patients under routine care without psychoeducation
both over 12- and 24-months follow up periods. Yet, Petretto et al.
(2017) could find no significant effects for family interven-tions on
medication compliance when investigating family psy-choeducation
for schizophrenia (Petretto et al., 2017).

Effects of the BFPEP on quality of life and social functioning

of patients

In our study, the SFQ was used to assess the different

dimensions of social performance of patients and the QLS was
used to assess the quality of life and functioning of the patient.
Statistically sig-nificant improvements were detected in social
functioning and quality of life of patients in the case group
compared to controls after 6 months, both on total scores and
subscales. This can be explained by the impact of teaching the
patients and their care-giver’s communication skills, leading to
better communication pat-terns inside the patient’s house, and
also, better communication with people outside the house both
of which are important in helping patients achieve better social
achievements and quality of life.

A Cochrane review confirmed that family interventions led to

measurable improvements in patient social functioning with data
from the social functioning scale favouring family intervention
groups, but doubts remain about the study’s robustness given the
small number of participants (Pharoah et al., 2010). A review of
several studies investigating the impact of family psychoeducation
on psychosocial functioning concluded that family interventions may
have a significant impact on functional outcomes in patients with
schizophrenia (on global and social functioning, social rela-
tionships, interest in obtaining a job, and management of social
conflicts) and their families (on social contacts and perception of
professional support) (Rummel-Kluge & Kissling, 2008b).

Magliano et al. (2006) found a significant improvement in

patients social relationships, interests in obtaining a job, mainten-
ance of social interest and management of social conflicts in an
intervention group receiving a psychoeducational programme for 6
months. Similarly, significant improvements in all aspects of patient
social functioning in the intervention groups receiving a
psychoeducational programme and followed up for 12 months was
recorded by Aguglia et al. (2007) and Chien and Chan (2004). In
addition, Chien and Chan (2004) reported the benefits of family
intervention over one year across a broad range of social function-
ing variables, such as living ability, social role functioning, and work.
Similarly, Hussein et al. (2006) found significant improve-ments in
social functioning in the patient group over 2 years, and Abolmagd
et al. (2004) found a statistically significant improve-ment in
performance on many items of quality of life domains among the
patient group compared to the control group.
 El-Shafei (2002) found a significant difference in the PANSS total
INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 7
score in the patient group compared to controls but contrary to our
results, no significant difference was found in the mean scores of
patients on the SFQ or any of its subscales compared to the control
group. This can be explained by the fact that El-Shafei (2002) used
programme formed of 3 sessions and the assessment was after
a short-term family intervention educational pro-gramme that tends
3 months.
to improve relatives’ knowledge of the illness and sense of mastery
in coping it and decrease the experience of its burden. However,
Hogarty et al. (1991), investigating only unrelapsed patients, did there is the lack of evidence supporting the effectiveness of these
not find any consistent significant differences in measures of role programmes for improving the long-term course of schizophrenia,
performance to favour the family intervention group at either 9- including relapse and rehospitalisations,
month or 2-year follow-up, although they did find that more patients
from the family intervention group were working at 2 years. This can
be explained by the fact that the evidence for the effectiveness of a
6–9-month family psychoeducation interven-tions for reduction of
relapse (and other outcomes) among patients is not as strong for
patients who have not had a recent illness exacerbation compared
to those who have had a recent ill-ness exacerbation (Dixon et al.,
2010). Similarly, Falloon, McGill, & Pederson, Boyd (1987), included
relapsed and unrelapsed patients and reported that BFT resulted in
significant improvements in social relationships, household tasks,
work activity and leisure activities over a two-year treatment period
compared to the standard treatment and observed that many of the
improvements in social functioning occurred during the second year
which sug-gested that the emphasis in the first year on developing
problem-solving skills may have contributed to the longer-term
benefits. Since our study used a similarly intensive programme,
follow up of patients receiving BFPEP in our sample may reveal
additional improvement in their social functioning and quality of life
in the longer-term.

Differences in outcome measures for BFPEP and controls

On comparing the mean scores for the outcome measures for

PANSS, DAI, QLS and SFQ in patients receiving BFPEP and con-
trols, there was a statistically significant difference (p<.05) between
the two groups on all scores favouring the group receiv-ing BFPEP.
Therefore, BFPEP resulted in significant improvements of the
clinical condition, compliance to medication, quality of life and social
functioning of patients compared to STU. This can be attributed to
the more structured sessions the BFPEP, with more information
about the illness and medications, interactive training sessions on
communication skills and problem-solving skills being provided
compared to treatment as usual.

A Cochrane review comparing standard treatment with family

interventions showed that family interventions significantly reduced
levels of relapse, hospital admissions and high expressed emotions,
leading to measurable improvements in patient social functioning
and treatment engagement (Pharoah et al., 2010).

Rummel-Kluge & Kissling (2008b) reported that patients with

schizophrenia receiving a psychoeducational programme had sig-
nificantly lower hospitalisation rates after 12 and 24 months com-
pared with standard treatment without psychoeducation (Rummel-
Kluge & Kissling, 2008b). Long-term (7 years), readmission rates
were reported to be lower in the psychoeducation group (54%)
compared to the standard group (88%) (B€auml, Frobose,€
Kraemer, Rentrop, & Pitschel-Walz, 2006).
 The authors thank the patients and their families who dedi-
8 A. H. KHALIL ET AL.
cated their time and attention to participate in this work.

the effect on patient quality of life and social functioning

(Solomon, Draine, & Mannion, 1996; Vaughn et al., 1992). Disclosure statement

No potential conflict of interest was reported by the authors.

Limitations

There were a number of limitations to our study. There was a large

References
dropout of initial participants, whereof the original 114 par-ticipants,
54 either failed to show up to the first assessment (des-pite being
scheduled and reminded of the date) or changed their minds about
participating because of the number and schedule of sessions that Abolmagd, S., El Raay, L., Akram, A., Amin, M., Abdel Aziz, H., & El
were involved in the study, which they found too excessive to Lawindi, M. (2004). Schizophrenic patients’ families psycho-
comply with. In addition, ideally, the researcher meas-uring the
outcomes should have been blinded to the group mem-bership of
study subjects. Yet, in this study blinding was not possible, so this
could have introduced an element of bias. Also, a larger sample of
patients would have been more representative, covering wider
socio-demographic and clinical aspects. However, the size of our
sample was adequate and covered a large catch-ment area that
serves patients of all social strata. Additionally, lon-ger-term
effectiveness of the programme could not be assessed which would
be better judged by a study of longer duration (2–3 years). Also, we
did not carry out any economic analysis and cost-effectiveness
evaluation for the programme.

Conclusions

Our findings suggest that the implementation of family psycho-

educational programmes has a positive impact on patients with
schizophrenia as regards improvements in symptomatology, com-
pliance to treatment, patient quality of life and social functioning. In
our study, we covered a broad range of outcome measures than
many previous studies. Our findings suggest that spending time and
effort for providing family psychoeducational pro-grammes for
patients of schizophrenia and their families is worth-while.
Therefore, any comprehensive treatment approach to patients with
schizophrenia should include family psychoeduca-tion as one of its
key components. This will increase patient know-ledge about
schizophrenia and will have a positive impact on their attitudes
towards their illness. It will also improve the social functioning,
quality of life and the clinical condition of patients.

Acknowledgments

The authors thank Prof. Lisa Dixon M.D., M.P.H., Professor of

Psychiatry, University of Maryland, School of Medicine, Director
of the Division of Health Services Research for her support in
training one of the researchers and providing the handout of the
training material. The authors would like to also express their
gratitude to Dr. Ahmed El Shafei and Dr. Moataz Ragheb and
the research team in the Institute of Psychiatry, Ain Shams
University for their help throughout the study.
 patients with Schizophrenia. Psychiatric Services, 55, 1276–
1284. doi:10.1176/ appi.ps.55.11.1276

education: Outcomes on patients quality of life and disease
relapse rate. Egyptian Journal of Psychiatry, 23, 1–10.
Aguglia, E., Pascolo-Fabrici, E., Bertossi, F., & Bassi, M. (2007).
Psychoeducational intervention and prevention of relapse
among schizophrenic disorders in the Italian community
psychi-atric network. Clinical Practice and Epidemiology in
Mental Health, 3, 7–17. doi:10.1186/1745-0179-3-7
Christenson, J. D., Crane, D. R., Bell, K. M., Beer, A. R., & Hillin, H.
H. (2014). Family intervention and health care costs for Kansas
Medicaid patients with schizophrenia. Journal of Marital and
Family Therapy, 40, 272–286. doi:10.1111/jmft.12021
Claxton, M., Onwumere, J., & Fornells-Ambrojo, M. (2017). Do
fam-ily interventions improve outcomes in early psychosis? A
sys-tematic review and meta-analysis. Frontiers in
Psychology, 8, 371. doi:10.3389/fpsyg.2017.00371

Assad, T., Okasha, T., Ramy, H., Goueli, T., El-Shinnawy, H., Nasr, M.,
Clifford, P. (1987). The social functioning questionnaire.
Research and Development in Psychiatry, 45, 808–813 .
… Shorab, I. (2015). Role of traditional healers in the
pathway to care of patients with bipolar disorder in Egypt. Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M.,
International Journal of Social Psychiatry, 61, 583–590. Dickinson, D., Goldberg, R. W., … Kreyenbuhl, J. (2010). The
doi:10.1177/ 0020764014565799 2009 schizophre-nia PORT psychosocial treatment
recommendations and sum-mary statements. Schizophrenia
Barrowclough, C., & Tarrier, N. (1997). Families of
Bulletin, 36, 48–70. doi:10.1093/ schbul/sbp115
schizophrenic patients: Cognitive behavioral intervention.
Cheltenham: Stanley Thornes.
Dyck, D. G., Short, R. A., Hendryx, M. S., Norell, D., Myers, M.,
Patterson, T., … McFarlane, W. R. (2000). Management of
B€auml, J., Frobose,€ T., Kraemer, S., Rentrop, M., & Pitschel-
Walz, G. (2006). Psychoeducation: A basic psychotherapeutic
intervention for patients with schizophrenia and their families.
Schizophrenia Bulletin, 32, S1–S9. doi:10.1093/schbul/sbl017

Bird, V., Premkumar, P., Kendall, T., Whittington, C., Mitchell, J.,
& Kuipers, E. (2010). Early intervention services, cognitive-
behav-ioural therapy and family intervention in early
psychosis: Systematic review. British Journal of Psychiatry,
197, 350–356. doi:10.1192/bjp.bp.109.074526

Bradley, G. M., Couchman, G. M., Perlesz, A., Nguyen, A. T.,

Singh, B., & Riess, C. (2006). Multiple-family group treatment
for English- and Vietnamese-speaking families living with
schizo-phrenia. Psychiatric Services, 57, 521–530.
doi:10.1176/ ps.2006.57.4.521

Caqueo-Urızar, A., Rus-Calafell, M., Urzua, A., Escudero, J., &

Gutierrez-Maldonado, J. (2015). The role of family therapy in
the management of schizophrenia: Challenges and solutions.
Neuropsychiatric Disease and Treatment, 11, 145–151.
doi:10.2147/NDT.S51331

Carra, G., Montomoli, C., Clerici, M., & Cazzullo, C. L. (2007).

Family interventions for schizophrenia in Italy: Randomized
controlled trial. European Archives of Psychiatry and Clinical
Neuroscience, 257, 23–30. doi:10.1007/s00406-006-0677-z

Chan, S. W., Yip, B., Tso, S., Cheng, B. S., & Tam, W. (2009).
Evaluation of a psychoeducation program for Chinese clients
with schizophrenia and their family caregivers Patient
Education and Counseling. Patient Education and
Counseling, 75, 67–76. doi:10.1016/j.pec.2008.08.028

Chien, W.-T., & Chan, S. (2004). One-year follow-up of a

multiple-family-group intervention for Chinese families of

negative symptoms among patients with schizophrenia
attend-ing multiple-family groups. Psychiatric Services, 51,
513–519. doi:10.1176/appi.ps.51.4.513
El-Ghamry, R. H. (2010). Family psychoeducation and outcome
of schizophrenia: An Egyptian study. Cairo, Egypt: Ain Shams
University.
El-Missiry, A. (2003). Homicide and psychiatric Illness: An Egyptian
study. Cairo, Egypt: Ain Shams University.
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J.,
Greenwald, D. P., Javna, C. D., & Madonia, M. J. (1986).
Family psychoeducation, social skills training, and
maintenance chemo-therapy in the aftercare treatment of
schizophrenia: I. One-year effects of a controlled study on
relapse and expressed emotion. Archives of General
Psychiatry, 43, 633–642. doi:10.1001/
archpsyc.1986.01800070019003
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J.,
Greenwald, D. P., Ulrich, R. F., & Carter, M. (1991). Family
psy-choeducation, social skills training, and maintenance
chemo-therapy in the aftercare treatment of schizophrenia
II. Two-year effects of a controlled study on relapse and
adjustment. Archives of General Psychiatry, 48, 340–347.
doi:10.1001/ archpsyc.1991.01810280056008

El-Shafei, A. (2002). An educational program for knowledge and
atti-tude change in families of patients with schizophrenia.
Cairo, Egypt: Ain Shams University.
Falloon, I. R. H., McGill, C. W., Boyd, J. L., & Pederson, J. (1987).
Family management in the prevention of morbidity of schizo-
phrenia: Social outcome of a two-year longitudinal study.
Hussein, H., El-Shafei, A., & Okasha, T. (2006). Working with
families of patients with schizophrenia: A rewarding
alternative to clas-sical community care in developing
countries. Egyptian Journal of Psychiatry, 25, 11–17.
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and nega-
tive syndrome scale (PANSS) for schizophrenia. Schizophrenia
Bulletin, 13, 261–276. doi:10.1093/schbul/13.2.261

Psychological Medicine, 17, 59–66. doi:10.1017/

S0033291700012988

Fenton, W. S., Blyler, C. R., & Heinssen, R. K. (1997). Determinants

compliance in schizophrenia: Empirical and clinical findings.
Schizophrenia Bulletin, 23, 637–651. doi:10.1093/schbul/23.4.637

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., &

Benjamin, L. S. (1995). Structured clinical interview for DSM-
IV axis I disor-ders (SCID-I) in handbook of psychiatric
measures. Washington, DC: American Psychiatric Press.

Garcıa Cabeza, I., Sanchez Dıaz, E. I., Sanz Amador, M., Gutierrez
Rodrıguez, M., & Gonzalez de Chavez, M. (1999). Factors
related to treatment adherence in schizophrenic patients. Actas

Espanolas~ De Psiquiatrıa, 27, 211–216.

Glynn, S. M., Marder, S. R., Liberman, R. P., Blair, K., Wirshing,

W. C., Wirshing, D. A., … Mintz, J. (2002). Supplementing
clinic-based skills training with manual-based community
support sessions: Effects on social adjustment of patients
with schizophrenia. American Journal of Psychiatry, 159,
829–837. doi:10.1176/ appi.ajp.159.5.829

Heinrichs, R. W., Hanlon, T. E., & Carpenter, W. T. (1984). The

qual-ity of life scale: An instrument for rating the
schizophrenic def-icit syndrome. Schizophrenia Bulletin, 10,
388–397. doi:10.1093/ schbul/10.3.388

Hogan, T. P., Awad, A. G., & Eastwood, R. (1983). A self-report

pre-dictive of drug compliance in schizophrenia: Reliability
and dis-criminative ability. Psychological Medicine, 13, 177–
183. doi:10.1017/S0033291700050182

INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 9
Kemp, R. A., & David, A. S. (1996). Psychological predictors of insight
and compliance in psychotic patients. The British Journal of
Psychiatry, 169, 444–450. doi:10.1192/bjp.169.4.444
Kulhara, P., Chakrabarti, S., Avasthi, A., Sharma, A., & Sharma, S.
(2009). Psychoeducational intervention for caregivers of Indian
patients with schizophrenia: A randomised-controlled trial. Acta
Psychiatrica Scandinavica, 119, 472–483. doi:10.1111/j.1600-
0447.2008.01304.x
Nilsen, L., Frich, J. C., Friis, S., Norheim, I., & Rossberg, J. I.
(2016). Participants’ perceived benefits of family intervention
following a first episode of psychosis: A qualitative study. Early
Intervention in Psychiatry, 10, 152–159. doi:10.1111/eip.12153
Petretto, D. R., Lussu, C., Zuddas, C., Pistis, I., Piras, P., Preti,
A., & Masala, C. (2017). Meta-review of systematic and meta-
analytic reviews on family psychoeducation for schizophrenia.
Austin Journal of Clinical Neurology, 4, 1–10. doi:10.26420/
austinjclinneurol.2017.1107
Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family inter-
vention for schizophrenia. The Cochrane Database of Systematic
Reviews, 12, CD000088. doi:10.1002/14651858.CD000088.pub2

Lecompte, D., & Pelc, I. (1996). A cognitive-behavioral program to

improve compliance with medication in patients with schizo-
phrenia. International Journal of Mental Health, 25, 51–56.
doi:10.1080/00207411.1996.11449333
Leff, J., Berkowitz, R., Shavit, N., Strachan, A., Glass, I., &
Vaughn, C. (1989). A trial of family therapy v. a relatives group
for schizo-phrenia. The British Journal of Psychiatry, 154, 58–
66. doi:10.1192/bjp.154.1.58
Pitschel-Walz, G., Leucht, S., B€auml, J., Kissling, W., & Engel, R.
R. (2001). The effect of family interventions on relapse and reho-
spitalization in schizophrenia a meta-analysis. Schizophrenia
Bulletin, 27, 73–92. doi:10.1093/oxfordjournals.schbul.a006861
Ran, M. S., Chan, C. L., Ng, S. M., Guo, L. T., & Xiang, M. Z. (2015).
The effectiveness of psychoeducational family intervention for

Li, Z., & Arthur, D. (2005). Family education for people with schizo-
phrenia in Beijing, China: randomised controlled trial. The British
Journal of Psychiatry, 187, 339–345. doi:10.1192/bjp.187.4.339

Magliano, L., Fiorillo, A., Malangone, C., De Rosa, C., Favata, G.,
Sasso, A., … Maj, M. (2006). Family psychoeducational
interven-tions for schizophrenia in routine settings: Impact on
patients’ clinical status and social functioning and on relatives’
burden and resources. Epidemiologia E Psichiatria Sociale, 15,
219–227. doi:10.1017/S1121189X00004474

McFarlane, W. R., Link, B., Dushay, R., Marchal, J., & Crilly, J.
(1995). Psychoeducational multiple family groups: Four-year
relapse outcome in schizophrenia. Family Process, 34, 127–
144. doi:10.1111/j.1545-5300.1995.00127.x

Merinder, L. B., Viuff, A. G., Laugesen, H. D., Clemmensen, K., Misfelt,

S., & Espensen, B. (1999). Patient and relative education in
community psychiatry: A randomized controlled trial regard-ing its
effectiveness. Social Psychiatry and Psychiatric Epidemiology, 34,
287–294. doi:10.1007/s001270050146

Mueser, K., & Glynn, S. (1998). Best practice: Developing and pro-
moting empirically supported interventions. In K. S. Dobson & K. D.
Craig (Eds.), Family intervention for schizophrenia (pp. 157–186).
Newbury Park, CA: Sage Publications.

Naeem, F., Saeed, S., Irfan, M., Kiran, T., Mehmood, N., Gul, M.,
… Kingdon, D. (2015). Brief culturally adapted CBT for
psychosis (CaCBTp): A randomized controlled trial from a low-
income country. Schizophrenia Research, 164, 143–148.
doi:10.1016/ j.schres.2015.02.015

Nasr, T., & Kausar, R. (2009). Psychoeducation and the family bur-den
in schizophrenia: A randomized controlled trial. Annals of General
Psychiatry, 8, 17–16. doi doi:10.1186/1744-859X-8-17
10 A. H. KHALIL ET AL.

patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychological
Medicine, 17, 1–8. doi:10.1017/ S003329171500019

Ruggeri, M., Bonetto, C., Lasalvia, A., Fioritti, A., de Girolamo, G., Santonastaso, P., … Meneghelli,
A. (2015). Feasibility and effectiveness of a multi-element psychosocial intervention for first-
episode psychosis: Results from the cluster-randomized controlled GET UP PIANO trial in a
catchment area of 10 million inhabitants. Schizophrenia Bulletin, 41, 1192–1203. doi:10.1093/
schbul/sbv058

Rummel-Kluge, C., & Kissling, W. (2008a). Psychoeducation for patients with schizophrenia and their
families. Expert Review of Neurotherapeutics, 8, 1067–1077. doi:10.1586/14737175.8.7.1067 Rummel-
Kluge, C., & Kissling, W. (2008b). Psychoeducation in schizophrenia: New developments and
approaches in the field. Current Opinion in Psychiatry, 21, 168–172. doi:10.1097/

YCO.0b013e3282f4e574

Sellwood, W., Wittkowski, A., Tarrier, N., & Barrowclough, C. (2007). Needs-based cognitive-behavioural
family intervention for
patients suffering from schizophrenia: 5-Year follow-up of a randomized controlled effectiveness trial. Acta
Psychiatrica Scandinavica, 116, 447–452. doi:10.1111/j.1600-0447.2007.01097.x Solomon, P., Draine, J., &
Mannion, R. (1996). The impact of individ-ualized consultation and group workshop family education inter-
ventions on ill relative outcomes. Journal of Nervous and Mental

Disease, 184, 252–255. doi:10.1097/00005053-199604000-00009 Stanley, S., & Shwetha, S. (2006).

Integrated psychosocial interven-

tion in schizophrenia: Implications for patients and caregivers.

International Journal of Psychosocial Rehabilitation, 10, 113–128.

Tandon, R., Targum, S. D., Nasrallah, H. A., & Ross, R. (2006). Strategies for maximizing clinical
effectiveness in the treatment of schizophrenia. Journal of Psychiatric Practice, 12, 348–363.
doi:10.1097/00131746-200611000-00003

Vaughan, K., Doyle, M., McConaghy, N., Blaszczynski, A., Fox, A., & Tarrier, N. (1992). The
sydney intervention trial: A controlled trial of relatives’ counselling to reduce schizophrenic
relapse. Social Psychiatry and Psychiatric Epidemiology, 27, 16–21. doi:10.1007/ BF00788951