Literature Review: Application of Psycho-Education for Families that have Schizophrenia Patients

(	Tareq Abed Al Fattah Eteamah Correspondence: Tareq Abed Al Fattah Eteamah, B.Sc. R.N., Master degree in Psychiatric and Mental Health Nursing The Hashemite University Faculty of Nursing Zarqa 13115, Jordan Email: t_a_t_2006@yahoo.com

Abstract Psycho education is defined as systematic, structured, instructional information on the disorder and its treatment, which includes combined aspects of emotional education in order to enable the participants of patients as well as family members to cope with the illness. Family psycho education refers to a wide range of programs that provide education, support, and guidance to families about coping with mental illness, especially to family members of those with mental illness such as schizophrenia that is considered a severe, chronic brain disorder where it becomes difficult for persons to understand the difference between real and unreal situations, to think logically, to have appropriate emotional responses, and to behave appropriately at home or in social situations. Not only patients with schizophrenia suffer greatly from this illness, but also their family members. This literature review shows that Implementing psycho education programs to families of patients with schizophrenia who often play a vital role as caregivers, promotes recovery, and maintains mental health care services, also applying family psycho-education programs on those in the mental health care setting affects the mental care outcome in many dimensions. Key words: psycho-education, psychiatric, family psycho-education program, schizophrenia.

Introduction
Psycho education is defined as systematic, structured, instructional information on the disorder and its treatment, which includes combined aspects of emotion education in order to enable the participating patients as well as family members to cope with the illness (Christine, Gabriele, Walz, & Werner, 2006). Psycho-education programs are considered as evidence-based practice that has been shown to alleviate relapse rates and facilitate recovery of patients who have mental illness (Dixon et al., 2001).

The existence of family members around the patients with schizophrenia and those with other serious mental illnesses often play a vital role as caregivers; in order to assist those with schizophrenia disorder which is considered the most common disease in psychiatric clinics, and it is also a severe mental disorder with relatively poor prognosis compared with other mental disorders (Song et al., 2014). New trends point towards community-based care for patients with schizophrenia where family members can assist in health care and in management of these patients, and a system of evidence-based practices have arisen to meet family member's necessity for education, support and guidance (De Sousa et al., 2012). Different types of implantations referred to as "family psycho-education" programs, have been developed, progressed, and practiced around the world as schizophrenia rehabilitation programs (De Sousa et al., 2012)

Schizophrenia is a severe, chronic brain disorder that becomes difficulty for people, to understand the difference between real and unreal situations, to think logically, to have appropriate emotional responses, and to behave appropriately at home or in social situations. Not only patients with schizophrenia suffer greatly from this illness, but also their family members (The world health organization [WHO], 2013). From this need Family psycho education was originated and has been shown to be an effective intervention for patients who suffer from schizophrenia and their family members. Studies taken up by this author have shown the effectiveness of family interventions, and demonstrated it with community based-care psycho education (Song et al., 2014)

As mentioned in Smith et al 2010 who defined psycho education as any intervention that educates patients and their families about their illness with a view to improving their long-term outcome. In despite of this Smith et al., (2010) consider the main principal of psycho-education for schizophrenia disorder is to provide accurate and reliable information related to the disorder and make the family able to make decisions regarding the patient and their life as family.

What is Family Psycho education?
Family psycho education refers to a wide range of programs that provide education, support, and guidance to families about coping style with mental illness, through education that can provide information about the nature of mental illness and its treatment; family are taught to be more effective in problem solving and communication skills to cope with the challenges and prognoses of mental illness (Murray-Swank et al., 2012)

One of the main sets of characteristics that makes family psycho-education programs effective, includes the items of emotional support, education, resources during periods of crisis, and problem-solving skills. But the use of family psycho-education in routine practice has been limited because of barriers at the level of the patients and his or her family members, the clinician and the administrator, and the mental health authority that reflect the existence of behavior, knowledge-based, practical, coping methods to deal with problems and systematic implementation (Dixon et al., 2001).

Murray-swank et al., (2012) describe, the family psycho education approach is that the family should recognize that mental illness is a brain disorder and that families play a significant role in patient recovery, and rehabilitation. That supposes the main principle of family psycho education is the best possible outcomes for patients can be achieved through collaboration among professionals, health care team, consumers, and families. Also as mentioned before psycho education is considered as evidence-based practice that has been shown to alleviate relapse rates and facilitate recovery of patients (Dixon et al., 2001). Kluge, (2006) judge that family psycho education as well has become a strongly supported evidence-based practice in management of schizophrenia, through research and studies in this field that have been able to detect that psycho education in families of patients with schizophrenia can reduce the relapse rates of these patients, and positively affect the course of the patient's illness, and help the families to assist patients to better cope with the mental illness (Kluge, 2006).

When discussing the essential elements of family psycho-education include having different family psycho education programs that vary according to their content; almost all contain an educational component and a supportive or skill, and development component. The educational component typically provides information on the different types of mental disorder and the associated symptoms, the different treatments of mental disorder, comprehensive information on medications, community resources and public benefits, while the supportive or skill development component includes, problem-solving skills to assist families to better manage their associated symptoms, communication skills, strategies to reduce caregiver stress, and finally family members are encouraged to learn from one another's experience and expand their social network (Murray-Swank et al., 2012)

The family psycho-education programs have several evidence-based models that have been developed to address the needs of families of persons with mental illness behavioral family management, individual family psycho-education, multi-family groups, and family to Family (Murray-Swank et al., 2012); in detailing particular items of behavioral family management. This terms mean an individual family education approach is done in the family member's home, Sessions of the program focus on education about schizophrenia disorder, strategies for improved communication, and the development of new problem-solving strategies (Murray-Swank, et al; 2012). However, this model focuses on a strengths based approach, building on the family's strengths to assist the patients to recovery and rehabilitation (Murray-Swank et al., 2012). The Individual and family psycho education approach contains more engagement effort with the family and patient, as well as expanded education about mental illness and its treatment, and guidelines for recovery (Kluge, 2006). In this program the family receives education and support both in a group setting and in individual in-home sessions; this approach is fior working long-term with the family to ensure the patient's recovery (Murray-Swank et al., 2012). Multifamily groups: this approach focuses on behavioral family management and individual family psycho education. Firstly each family is met with individually after that multifamily group meetings are held which several members of the same family attend, and emphasizes to families to learn from one another, connecting families to one another, and building feelings of hope about the future (Murray-Swank et al., 2012)

During the writing this paper and searches of researches published in CINAHL Database, EMBASE, PsycINFO and ISI Web of Science, Pub Med Database, Medline, EBSCO, and Science Direct Databases, unfortunately I could not find accurate prevalence about family psycho education programs with schizophrenia patients.

The aim of this literature review is to clarify the family psycho education programs related to schizophrenia patients and to scope significant processes in effective family psycho education programs.

The Literature Review
Implementing the family psycho education programs of patients with schizophrenia often plays a vital role as caregivers promote recovery, and maintain mental health care services (Kluge, 2006). Additionally, through applying family psycho-education programs in the mental health care setting affects the mental care outcome in many dimensions (Kluge, 2006). In particular, family psycho education programs include reduced relapse rates and facilitate recovery of patients who have mental illness through providing emotional support, education, and problem-solving skills (Murray-Swank,et al., 2012), However, as Yoshio-Mino (2007), mentions family psycho education has been shown to prevent the relapse of schizophrenia, and to increase compliance to medication and effectiveness in coping with stressors which have been successful in reducing the risk of relapse in the first year following hospital discharge (Desousa-Foundation et al., 2012).

Jan Prasko et al., 2011 reports that schizophrenia disorder is a chronic psychiatric illness affecting 1% to 2% of the population. Schizophrenia patients commonky to relapse and require re-hospitalization The core intervention in schizophrenia remains only anti-psychotic medication; but use of family psycho educational program detects significant improvement in the schizophrenia patients post-hospital discharge with demonstrated effects on rehospitalization rates, and compliance with medication, and knowledge.

In a recent study by Petretto et al., (2013) who used a randomized controlled trial study in collaboration with the Italian National Health Services (NHS); the study composed 340 patients diagnosed with schizophrenia. The study continued for the duration of 6 months but patients were reassessed at 6, 12 and 18 months after the start of family psycho-education program session. The aim of this study was to evaluate effectiveness of the psycho education program in improving adherence to pharmacotherapy and in reducing relapse and readmissions. (Cohen's power =80% medium effect size effect size= 45% at a two-sided significance level of 0.05) The result observed a 25.5% rate of non-adherence to pharmacotherapy, but on opposite side, a 47% rate in adherence to pharmacotherapy, then concluded that the psycho-education program was effective in adherence to pharmacotherapy for patients diagnosed with schizophrenia-spectrum psychoses, improving communication and problem-solving abilities in patients and their families.

Rummel-Kluge et al., (2006) approved through a survey of all psychiatric Institutions in Germany, Austria, and Switzerland that psycho-education can reduce re hospitalization rates and mental health costs in schizophrenia disorder.

A study by J. Ba¨uml et al., (2006) confirmed family psycho educational interventions were accompanied by a higher level of compliance to medication, lower rate of relapse in health status, and improved psycho pathological status, through stress-coping model, with its assumption of a psycho educational interventions applied by an 'obligatory-exercise' program.

As did De Sousa, (2012) in his clinical review show the aim of psycho education programs to provide correct information about the disorder, treatments and long term course and prognosis of the disease, so this program effectively increased medication compliance and effectiveness in coping with stressors that successfully reflected in reducing the risk of relapse in the first year following hospital discharge, through empowering relatives of patients with schizophrenia.

A longitudinal experimental study examined the effect of patient and family education in a sample of Chinese people with schizophrenia, and used a randomized controlled trial in a large hospital with a sample of N=101 patients with schizophrenia and their families; the sample was divided into two groups, the first group was the intervention group which received family psycho education. There was a significant improvement in knowledge about schizophrenia in the experimental group and a significant difference in symptom scores and functioning at 9 months after discharge, but the other group that did not receive family psycho education showed relapse in schizophrenia disorder management (Arthur et al., 2005).

Summary and Conclusion
Family psycho education is programs that provide education, support, and guidance to families about coping styles with mental illness, which at the same time considers evidence-based practice that plays a vital role in reduced relapse rates and facilitates recovery of schizophrenia patients through family psycho education programs in which each process is to be completed through collaboration among professionals, health care team, patients and families. However, most of the studies on family psycho education program that have been investigated the benefits for patients when family members attend a psycho education program are associated with a lower risk for a psychiatric relapse, asmentioned before, and for families who attend a psycho education program it is discovered that these families have a high level of. On the other hand through research evidence it has been detected that family psycho education reduces family burden and increases feelings of empowerment at the same time. Families who attend psycho education programs report high levels of satisfaction with the program and show an increase in skills and knowledge about mental illness and its treatment (Murray-Swank et al., 2012)

Jewell, (2009) describes family psycho-education (FPE) as one from six evidence-based practices approved by the Center for Mental Health Services to patients who are suffering from chronic mental disorder especially, such as schizophrenia disorder and confirm an effective component of family psycho education (FPE) is in reducing symptom relapses and re hospitalizations for patients. The author gives details' about the effectiveness of the (FPE) component as, firstly when family members participate on a consistent basis, which allows them to increase their understanding of definition and the biology aspects of the disorder, secondary, to learn ways to be supportive, and reduce stress in the environment and in their own lives, then develop a broader social network, as well as when these components are used effectively in conjunction wtyh medication, family psycho education (FPE) can help an individual with schizophrenia progress towards the rehabilitation phase and recovery.

Practically family psycho education (FPE) program can be evaluated by the use of two tools that have been developed to monitor the effectiveness of FPE through: The FPE Fidelity Scale; and General Organizational Index, even though it may administer both tools at the same time; The FPE Fidelity Scale which has 14 program-specific items. Each item is rated on a 5-point scale, ranging from 1 (not implemented) to 5 (fully implemented). The items assess whether the program is provided as the evidence-based model prescribed. This scale was developed by a group of researchers at Indiana University-Purdue University, Indianapolis, but The General Organizational Index, developed by Robert Drake and Charlie Rapp, is a newly developed scale. This scale evaluates based on feedback gathered during pilot testing over a long time (Rockville et al, 2009).

Finally; in all previous literature reviews that confirm the effectiveness of family psycho education intervention, should review the factor that maintains optimal efficacy of family psycho education intervention and there should be focus on differences between family members in expressing needs for information, support and skills. In this paper the author confirms the need to deal and organize the needs of family members to adapt with providers to achieve the desired outcome, firstly; Providers can offer family members information about schizophrenia and other mental health system and community resources that they may find helpful, secondly providers can assist family members in learning effective and therapeutic communication with patients in addition to learning problem solving skills to be able to deal with individuals who have mental disorders and never create disruption and fear in phases of rehabilitation for patients; Thirdly, family member need support, to make sure they are building rapport, trust and good relationships with mental health providers and enhance the ability for family member to support each other and be helpful, especially to prevent stigma (Dixon et al., 2000).

Recommendations
After this study on family psycho education the author recommends that when applying family psycho education the program should mention effective steps in family intervention programs as should be the engagement of the family in the treatment process from the beginning and educate the family on "no fault" culture or stigma about schizophrenia disorder; educate the family about variations in prognosis and coping with the patients disorder; should confirm on rapport and therapeutic communication with patients and quality of relationship, and should not restricted patients but encourage them to express their emotions. At the end of this paper the author hopes applying and generalizing this intervention is considered seriously as a method for community-based care for family members who are involved in assistance in health care and in management of patients with schizophrenia.
The limitation in this literature review is that almost all articles that studied family psycho education for schizophrenia patients do not deal with statistics and numbers, for assessingknowledge about the extent of prevalence in family psycho education in schizophrenia patients in their culture and background.

Acknowledgement:
The author extends his appreciation to the college of nursing at the Hashemite University; specifically to professor Dr: Hassan Al-Omari, PhD.

References
Dixon L., McFarlane W., Lefley H., Lucksted A., Cohen, M., Falloon I., et al. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52, 903-910.
De Sousa A., Kurvey A., Sonavane S., et al. (2012). Department of Psychology, LS Raheja College, Mumbai, Department of Psychiatry; Family Psychoeducation for Schizophrenia: A Clinical Review, MJP-02-08-2012, 400054
Daniel Smith, Ian Jones, & Sharon Simpson et al., (2010). Psycho education for bipolar disorder; Advances in psychiatric treatment, Vol. 16, 147-154 doi:10.1192/apt. bp.108.006403
Murray-Swank L., Aaron B., Dixon L., Lisa K. et al.,(2012). Family Psycho education as an Evidence-Based Practice. CNS Spectrums, Vole 9(12), Dec 2012, 905-912.
Jan P., Kristyna V., Klara L., Barbor, M., (2011). Psychoeducation for Psychotic Patients; Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic, 155(4):385-396. DOI 10.5507/bp.2011.008
Donatella R., Petretto L., Antonio P., Carlo Z., Franco V et al., (2013). Study on psycho education enhancing results of adherence in patients with schizophrenia (SPERA-S): study protocol for a randomized controlled trial, Department of Education, Psychology, Protocol Registration System of Clinical Trials.gov, 12, NCT01433094
Christine, R., Gabriele, P.,Walz J., & Werner K, (2006). Psycho education in Schizophrenia-Results of a Survey of All Psychiatric Institutions in Germany, Austria, and Switzerland; Department of Psychiatry and Psychotherapy, Universita¨t Munchen, Mo hlstrasse 26, 81675 Munchen, Germany, vol. 32 no. 4 pp. 765-775, 14,2006 doi:10.1093/schbul/sbl006
Josef Ba¨uml1, Teresa F., Sibylle K., Michael R., & Gabriele P., Walz L.(2006). Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families; hospital of psychiatry and psychotherapy, technical university of Munich, Ismaninger strasse, Germany, vol. 32 no. s1 pp. s1-s9, 18,2006 doi:10.1093/schbul/sbl017
Thomas C., Jewell L., Donna D., William R., McFarlane R., (2009). Partnering With Families: Multiple Family Group Psycho education for Schizophrenia; Journal of Clinical Psychology: In Session, doi: 10.1002/jclp.20610, Vol. 65(8), 868-878, (2009),
Lisa D., Curtis A., Alicia L., (2000). Update on Family Psych education Schizophrenia, Psychiatric department, Schizophrenia Bulletin , Vol. 26, No(1);5-20,2000
Rockvill, et al (2009). Substance Abuse and Mental Health Services Administration, Family Psycho education: Evaluating Your Program. HHS Pub. No. SMA-09-4422, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
Liz, D et al,(2005). Family education for people with schizophrenia in Beijing, China: randomized controlled trial. British Journal of Psychiatry, (2005). 187:339-45.
Yan Song L., Dan L., Yuxiang C., Guoping H et al, (2014) Using focus groups to design a psycho education program for patients with schizophrenia and their family members; School of Nursing Central South University, 172, Tongzipo Road, Hunan, Changsha 410013, China, 2014; 7(1):177-185.
World Health Organization Website. (2013). Retrieved October 21, 2013 from, http://pro.psychcentral.com/2013/dsm-5-changes-depression depressive disorders/004259.html#
Website: PsycINFO Database Record (c) 2012