آموزش روانی خانواده و مداخلات متمرکز اتحاد درمانی برای پدر و مادر یک دختر و یا پسر با یک بیماری روانی شدید

Abstract This study compared the effectiveness of a family psychoeducational intervention (FPEI) and a therapeutic alliance focused intervention (TAFI) for parents of daughters and sons with severe mental illness (SMI). A process-outcome model was used to compare the effectiveness of the two interventions and to evaluate how they achieved their outcomes. Extent of effectiveness was assessed in terms of the family burden (FB) of the parents and the quality of life (QoL) and psychiatric symptoms of the daughters and sons. This study did not uncover a difference in effectiveness between the two interventions. However, at post-treatment, the participants in both interventions reported statistically significant less FB and attributed more QoL and less psychiatric symptoms to their daughters and sons than at pre-treatment. In addition, these pre- and post-treatment differences were mediated by specific mediating variables. These results are discussed in terms of the great psychotherapy debate (Wampold, 2001) as to the relative effectiveness of technique oriented interventions as compared to context oriented interventions.

1. Introduction Such severe mental illnesses (SMI) as schizophrenia generally emerge between the ages of 16 and 30 years old (Almeida et al., 1995). This age range involves significant challenges to the person with the SMI and that person's family with regard to establishing personal and interpersonal independence (Malla et al., 2005). Therefore, SMI tends to influence and to be influenced by the child–parent relationship and family quality of life (QoL) and the QoL of the individual with the SMI. On one hand, research has shown that family members, especially parents, can impact both positively and negatively on the treatment and the rehabilitation of persons with a SMI (Birchwood and Smith, 1990, DeChillo et al., 1994 and East, 1992). On the other hand, many investigations of the families of persons with a SMI indicate that these families experience extreme burden (Coyne et al., 1987, Gibbons et al., 1984 and Spanoil, 1987). Subsequently, over the last two decades, various interventions for family members of persons with SMI have been developed both to facilitate the treatment and rehabilitation of these persons (McFarlane et al., 2003) and to ameliorate the negative consequences of these persons' illness for the family. Several studies have been carried out to evaluate the effectiveness of the various interventions that have been developed for family members of persons with SMI (Barlow, 1996, Chambless, 1996, Chambless et al., 1998 and Lehman and Steinwachs, 1998). In particular, evidence has accumulated in support of the contention that various forms of family psychoeducation interventions (FPEI) are effective in reducing family burden and in improving both the communication between parents and their children and the QOL of the family and of the individual with the SMI (Jewell et al., 2009, McFarlane et al., 2003, Montero et al., 2001, Mueser and Glynn, 1999 and Nasr and Kausar, 2009). Therefore, these interventions are considered evidenced based practices (EBP) in the field of psychiatric rehabilitation (Dixon et al., 2001). However, other studies have not replicated the findings that showed psychoeducations to be effective (Pekkala and Merinder, 2001). The psychoeducation approach, because it is problem focused (Mcfarlane et al., 2003) emphasizes the techniques it uses as a major determinant of change (Barlow, 1996 and Chambless, 1996). According to Wampold's (2001) conceptualization of what he terms the great psychotherapy debate between those theoreticians who attribute the effectiveness of psychotherapy to specific techniques and those theoreticians who attribute this effectiveness to a set of common factors, family psychoeducation would be most consistent with the medical model of psychotherapy. A medical model orientation to such psychosocial interventions as psychotherapy assumes that these interventions consist of sets of techniques designed to remediate specific problems, symptoms or complaints (Wampold, 2001). Those theoreticians who claim that a set of common factors are the principle determinants of the effectiveness of different interventions argue that specific techniques contribute little to these interventions' effectiveness (Teyber and McClure, 2000 and Wampold, 2001). The quality of the therapeutic alliance established between a client and a clinician is a major common factor that has been shown to underlie the effectiveness of different psychosocial interventions (Fancher, 1995 and Frank and Frank, 1991). Bordin, 1975, Bordin, 1976 and Bordin, 1980 is accredited with identifying the therapeutic alliance as a core ingredient of psychotherapy. According to Bordin, 1975 and Bordin, 1980, the therapeutic alliance enables the client to accept and comply with treatment. He claimed that the therapeutic alliance consists of establishing an affective bond between therapist and client and achieving agreement between therapist and clients on the goals of therapy and on the means of attaining these goals. Evidence has been uncovered showing that the therapeutic alliance contributes significantly to positive change in psychotherapy in a variety of settings (i.e., individual psychotherapy (Beutler et al., 2004 and Horvath and Bedi, 2002) family therapy (Sprenkle and Blow, 2004), group therapy (Marziali et al., 1997), and family group therapy (Brown and O'Leary, 2000). The present study applied a process–outcome research design to examine two family interventions that are aimed at achieving a positive change in the lives of parents of persons with SMI and in the lives of these parents' daughters and sons with a SMI. These interventions were a family psychoeducation intervention (FPEI) and a therapeutic alliance focused intervention (TAFI). Thus, these studies compared an intervention that applies techniques designed to remediate specific problems, symptoms and complaints to an intervention that emphasizes the establishment of a relationship between the client and clinician assumed to be conducive to engendering positive change. The effectiveness of the two interventions was evaluated in terms of their differential impact on common outcome variables that could be affected by either intervention. Furthermore, intervening variables theoretically associated with the processes by which the interventions were expected to achieve these outcomes were examined. Certain of these processes could be theoretically linked to either of the interventions whereas other processes appeared to be theoretically associated specifically with one of the interventions. The outcome variables were QoL, psychiatric symptoms and family burden, and the mediator variables were hope, internalized-stigma, therapeutic alliance and expressed emotion. Thus, in terms of outcome, both the FPEI and the TAFI could reduce the family burden of the parents and the symptoms of the daughters and sons with a SMI and to increase these sons' and daughters' QoL. However, if the component of intervention most responsible for these improvements consisted of the psychoeducation techniques, this improvement should be significantly greater for the FPEI than for the TAFI whereas the opposite results were expected if the therapeutic alliance was the more effective therapeutic component. In addition, each of the interventions was assumed to achieve the above outcomes due to their impact on different processes represented by different intervening variables. For the FPEI, variables such as parent's expressed emotions and internalized stigma were assumed to be related to the psychosocial educational technique applied by the intervention whereas for the TAFI, variables such as the quality of the therapeutic alliance and hope that were assumed to reflect factors common to effective therapy should be the intervening variables. The FPEI was expected to reduce expressed emotion and self-stigma whereas the TAFI was expected to create a more positive therapeutic alliance and to increase hope (see Fig. 1). Mediating models for TAFI and FPEI. According to these models, TAFI achieves it ... Fig. 1. Mediating models for TAFI and FPEI. According to these models, TAFI achieves it effect by impacting positively on the quality of the therapeutic alliance and on hope whereas FPEI achieves its effects by reducing expressed emotion and internalized stigma.

3. Results 3.1. The study's hypotheses On the basis of a summary of theories and empirical findings regarding therapeutic change labeled the great psychotherapy debate (Wampold, 2001), this study tested a set of alternative hypotheses. These hypotheses were inferred from a technique oriented approach to psychosocial interventions as compared to a relationship oriented approach to these interventions. On one hand, according to the technique approach, parents who are taught to apply the appropriate techniques should experience less family burden while their daughters and sons should experience more QoL and less symptoms. On the other hand, according to the relationship oriented approach, parents with whom the appropriate therapeutic relationship is established should experience less family burden while their daughters and sons should experience more QoL and less symptoms. In addition, these different approaches to therapeutic and intervention effectiveness predict different major process–outcome relations. According to the technique oriented intervention, the putative effectiveness of the FPEI in reducing FB and psychiatric symptoms and in improving daughter and son QoL should be due to the impact of the FPEI on EE and self-stigma whereas, according to the relationship oriented approach, the above achievements should be due to the impact of the TAFI on hope and on the quality of the therapeutic relationship. 3.2. The effectiveness of the interventions Two-way ANOVAs and ANOCOVAs were used to assess both the differential impact of the FPEI and the TAFI on family burden (FB), and on the QoL and psychiatric symptoms of the daughter or son as perceived by the parents and on the processes by which this impact was achieved. Two-way ANOVAs with the different interventions as the between subject independent variable and time one (pre-intervention) and time two (post-intervention) as the within subject independent variables were applied to the dependent variables, the parents' FB and the daughters' or sons' QoL. These analyses were carried out to determine whether statistically significant changes occurred between times one and two and whether there were statistical grounds for attributing such gains to one of the two interventions. Two-way ANACOVAs with the same independent variables and expressed emotion (EE), hope, internalized stigma (IS), and quality of therapeutic alliance as the covariants were carried out when either a statistically significant main effect was uncovered for time or when a statistically significant interaction between the two independent variables was found. The results of these analyses are presented for each of the dependent variables separately. The two way ANOVAs uncovered neither a statistically significant main effect for type of intervention nor a significant interaction effect for the intervention ∗ time intervention for any of the dependent variables. However, a statistically significant main effect was found for time for FB (F(1,81) = 13.83, P < 0.001, eta = 0.14), for overall QoL (F(1,81) = 5.27, P < 0.05, eta = 0.05) and psychiatric symptoms (F(1,81) = 8.08, P < 0.01, eta = 0.06). In addition, borderline statistical significance was found for psychological health (F(1,81) = 3.28, P = 0.07, eta = 0.03) and for social relations and support (F(1,81) = 3.29, P = 0.07, eta = 0.03). Table 2 presents the means and SDs for FB, psychiatric symptoms and for the different measures of QoL. As can be seen from this table, for all of these measures with the exception of family burden and psychiatric symptoms, time two scores were higher than time one scores. For family burden and psychiatric symptoms, time two scores were lower than time one scores. Table 2. Mean, standard deviation and range of QOL subscales at times 1 and time 2. Mean SD Range Time 1 Time 2 Time 1 Time 2 Time 1 Time 2 Total QoL 2.60 2.64 0.48 0.54 1.52–3.68 1.40–4.08 Physical health 2.24 2.34 0.59 0.55 1.00–3.33 1.00–3.33 Social relations and support 2.26 2.34 0.67 0.73 1.00–3.75 1.00–4.00 Psychiatric symptoms 2.43 2.24 0.99 0.93 1.04–5.81 1.00–5.00 Family burden 2.51 2.35 0.54 0.54 1.24–3.69 1.17–3.55 Table options On the assumption that the above described statistically significant main effects are indicative that the two interventions were equally effective, covariance analyses were performed to determine which of the mediating variables accounted for this effectiveness. For this purpose, Pearson product–moment correlations and ANCOVA analyses were carried out separately for each of the dependent variables for all of the putative mediating variables. The results of the ANACOVAs are reported separately for each of the dependent variables. 3.3. Family burden A significant positive correlation was uncovered between FB and IS (r = 0.58, p < 0.001) and significant negative correlations were uncovered between FB and hope (r = − 0.24, p < 0.05) and the quality of therapeutic alliance (r = 0.22, p < 0.05). Four ANACOVAs with repeated measures for time (pre- and post-intervention) were carried out with each of the putative mediating variables as a covariate. For these analyses, type of intervention was the between subject independent variable and time of measurement was the within subject independent variable. When IS and EE were the covariates, the positive change in the levels of FB that was found in the previous analysis was not reduced. However, the positive change in FB level was no longer significant when hope was the covariate (F(1,89) = 0.53, p > 0.05) as well as when the therapeutic alliance was the covariant (F(1,89) = 2.65, p > 0.05). Thus, hope and the therapeutic alliance, but not IS and EE, seems to mediate the reduction in FB between time one and time two. 3.4. Quality of life and psychiatric symptoms A statistically significant negative correlation was uncovered between EE and the overall QoL (r = − 0.53, p < 0.01), and a significant positive correlation was uncovered between EE and the symptoms subscale of the QoL measure(r = 0.41, p < 0.01). ANOCOVA with repeated measures for time (pre- and post-intervention) was carried out with all of the putative mediating variables as the covariates. Type of intervention was the between subject independent variable and time of measurement was the within subject independent variable. Overall QOL and psychiatric symptoms were the dependent variables. EE, IS and hope as the covariates did not significantly reduce the positive change in the levels of QOL that was found in the previous analysis. However, the positive change in the symptoms' level was no longer significant with EE as a covariant (F(1,87) = 0.27, p > 0.05). Thus, EE seems to mediate the reduction in symptoms' level between time one and time two.