Hope and recovery in a family treatment for schizophrenia: a program evaluation of a family psychoeducational intervention

© 2014 Dr Laura HayesA focus on recovery is increasingly widespread in practice and policy in services for people with schizophrenia and their families. Recovery principles suggest that hope is integral to recovery, which can occur (and implicitly hope can improve) independent of the symptomatic severity of mental illness. However, there is little research on this or recovery-focused services in general. This is a concern for services wishing to evaluate the provision of recovery-focused practices. Unless the relationship between hope and recovery is investigated broadly, the understanding and evaluation of recovery is compromised. Over 50 RCTs demonstrate the effectiveness of family psychoeducation (FPE) in reducing relapse in consumers and burden in carers. Although not studied previously, FPE appears well suited to improve hope and recovery because it develops purpose and support within families. This study investigated (1) the trajectory of hope, recovery and symptoms across an FPE program; and (2) the usefulness of a hope model which defined hope as the positive expectancy of achieving goals through optimism and self-efficacy. Emergent hope, in contrast, emphasises the beginning of hope as the “tiny fragile spark” in the midst of adversity. Method: The study used a mixed-methods, quasi-experimental design with consumers and relatives selected for FPE suitability, compared to TAU, conducted in community mental health centres in disadvantaged suburbs. Assessments conducted before and after 10 months of FPE or TAU included: hope, consumer functioning and symptoms; and carer distress and burden. Treatment satisfaction was assessed in participants from the treatment cohort. Results: 62 consumers and 63 carers were recruited across treatment and TAU cohorts; most consumers had persistent symptomology and fifty percent had co-morbidities. Average hope in consumers and carers was significantly below community norms. Higher symptoms were correlated with reduced hope. There were no changes over time in outcomes and no significant differences between FPE and TAU groups. Carers expressed some hopes in terms of positive expectancy and self-efficacy, but also discussed hopes without optimism for their attainment. Consumers did not express their hopes in terms of goals, motivation and planning. However, in the absence of objective changes, participants reported high levels of satisfaction with FPE. Conclusion: These results emphasise the lack of hope in consumers with severe and enduring mental illnesses and the need for new ways to address this important problem. The lack of treatment effect for FPE could not be attributed to low statistical power; the findings suggest there are considerable challenges in restoring hope and achieving recovery for this group of consumers. The study demonstrates the difficulties in translating evidence from successful efficacy trials into effective recovery-based programs. Hope was not independent of symptoms, consistent with other research, but not the recovery paradigm. A nuanced reading of recovery narratives suggests that while recovery can occur despite the persistence of symptoms, it is not a given. In the early stages of recovery and low levels of hope, symptoms can dominate positive expectancies. As a mix of optimism and efficacy, expectancy hope showed limited relevance, as it could not account for carer hopes expressed in the face of considerable adversity. Lower hope levels might be better assessed using emergent models of hope. These findings encourage closer attention to the successful implementation of FPE in routine practice, more research into the relationship between hope and recovery, and the need for suitable models and measures of hope to evaluate recovery-focused services