The impact of an empowerment intervention on people with schizophrenia: Results of a randomized controlled trial

Abstract

Aims:

The aim of the study was to assess what empowerment intervention has on people with schizophrenia.

Methods:

A randomized controlled trial was carried out between November 2015 and May 2016 involving 112 participants who had been diagnosed with schizophrenia. Patients, who were 18 years and above diagnosed with Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) schizophrenia or schizoaffective disorder from the outpatient mental health clinics in Jordan, were randomly assigned to take part in an intervention that consisted of receiving 6 weeks’ worth of information booklets, with face to face discussions, while receiving their usual medication or allocated treatment as usual. The participants were assessed at baseline, immediately after the intervention and at 3-month follow-up. The primary outcome was a change in the helplessness score. Secondary outcomes were psychiatric symptoms, recovery rate, empowerment and quality of life.

Results:

This study showed that people with schizophrenia in the intervention group showed more improvement in the helplessness score immediately post-intervention (F = 74.53, p < .001) and at 3-month follow-up (F = 75.56, p < .001), they reported significant improvements in all secondary outcomes.

Conclusion:

This study indicated that the empowering intervention was an effective intervention when integrated with treatment as usual.

Keywords

Schizophrenia empowerment recovery

Introduction

Living with psychosis is a very traumatic experience (Lodge, 2010). Patients do not know what to expect as psychosis is highly unpredictable and symptoms vary (Lysaker, Roe, & Buck, 2010). Up until now, there have been ample studies that have discussed how patients recover from schizophrenia. Those that have been published, however, have demonstrated that a lack of psychopathology in some people with schizophrenia (PwS) can lead to them living a moderately fulfilling life (Ng et al., 2008). Nevertheless, most PwS experience psychiatric symptoms getting worse over time and have relapses (Chan, Yip, Tso, Cheng, & Tam, 2009).

Many PwS can remain symptom free and others can lead reasonably productive lives. However, the majority of them still experience a degree of impairment of function, and many will suffer relapses or chronic levels of their positive symptoms (Warner, 2009). The recovery of PwS means they have gone into remission with psychiatric symptoms. However, recovery is considered to be a multifaceted concept, comprising many different elements, such as being productive, living independently and sustaining close relationships with others (Warner, 2009). On the other hand, most PwS think they have recovered after they have received healthcare, which leads them to feeling hopeless and/or helpless (Corrigan, Rafacz, & Rusch, 2011). However, healthcare professionals do not think about hopelessness or helplessness, rather they think that PwS are not capable of addressing their own feelings, as they do not understand their illness (Berry, Allott, Emsley, Ennion, & Barrowclough, 2014).

The idea of recovery from serious mental illnesses such as schizophrenia must include both a patient’s subjective experiences and measurable objective outcomes (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011; Slade, 2009). Traditional clinical definitions of recovery are associated with individuals returning to a state of ‘normality’ as experienced prior to the episode of ill health, having found a ‘cure’ (Law & Morrison, 2014; National Institute for Health and Clinical Excellence [NICE], 2009). In the context of mental illness, recovery is defined as the complete or almost complete remission of psychiatric symptoms and impairments, and it is not associated with partial improvements in symptoms. Meanwhile, recovery as defined by Substance Abuse and Mental Health Services Administration (SAMHSA) is a process that may or may not involve symptom reduction and restoration of function (Rudnick, 2008). Still, others define recovery as being akin to a clinical recovery, or simply a reduction of symptoms and role dysfunctions leading to at least some psychological recovery (Slade, 2009). Another way of looking at it might be the restoration of patient’s self in the world. Recovery-oriented services are increasingly being called for around the world, and these services do not consider recovery from mental illness to merely include symptom remission; they are more interested in individuals’ abilities to redefine their selves and to ‘live well’, even where symptoms endure (Soundy et al., 2015). One aspect of recovery is the development of everyday well-being; this includes developing environmental mastery, personal growth, life purpose, increased autonomy, self-acceptance and positive relations with others (Eisenstadt, Monteiro, Diniz, & Chaves, 2012; Slade et al., 2014). Several factors have been identified as facilitating such recovery, including hope, acceptance of illness, self-responsibility, optimal treatment and supportive environments (Soundy, Kingstone, & Coffee, 2011; Soundy et al., 2015).

Recovery in these terms is less about getting rid of symptoms or problems and more about developing greater degrees of hopefulness, meaning and purpose in life, along with a positive sense of identity that goes beyond simply thinking of oneself as a person with a mental illness (Andresen, Oades, & Caputi, 2003). Personal recovery has been described as a journey of growth involving taking control and responsibility for one’s life (Torgalsbøen & Rund, 2010). However, many service users rely on a more subjective definition of recovery, reflecting the process in which an individual’s social identities are developed and reconstructed, and, to some extent, suffused with the stigma of the ‘illness identity’. This definition has now been widely adopted by service providers and supports increased participation in life, social connectedness, empowerment and hope (Giusti et al., 2015). Recovery must involve biological, psychological and environmental changes, and hence the range of treatment options available to achieve these changes is both broad and evolving (Soundy et al., 2015). It can include pharmacotherapy, case management, cognitive remediation, family treatment, integrated dual diagnosis treatment, psychotherapy, skills training and empowerment intervention, as part of a non-exhaustive list (McCauley, McKenna, Keeney, & Mclaughlin, 2015).

There is a need for recovery orientation to have interventions and practices to be carried out in line with the results of patient assessments (Noh, Choe, & Yang, 2008). This is in addition to practices that are based on the identification of the patient’s own personal strength and capabilities, which will aid in self-efficacy of managing their own illness and help them regain their place in society and the community (Davidson, O’Connell, Tondora, Styron, & Kangas, 2006). Thus, it is vital to develop effective interventions and interventions that can help to improve the practical and independent well-being of patients (Tolman & Kurtz, 2010).

In terms of recovery orientation from the Jordanian perspective, there are a range of barriers to supporting people in their personal recovery. A recent qualitative study by Hasan, Callaghan, and Lymn (2017) reported that schizophrenia is the result of a demonic possession of their relative’s mind, prompting them to say or do inappropriate things. Consequently, they attempted to treat schizophrenia by consulting folk exorcists to dispel these spirits. In fact, Slade (2010) recognized this as an environmental factor which hinders or delays recovery. Additionally, people diagnosed with schizophrenia are stigmatized and discriminated against in Jordanian society. Thus, stigma might be a barrier to individuals with schizophrenia having the opportunity to develop the valued social roles or more positive identity that would be considered essential to their personal recovery (Al-Krenawi & Graham, 2000; Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2009). Furthermore, poor infrastructure of the mental health service in Jordan has a large impact on the recovery of PwS (World Health Organization, 2008). Taken together, it has a direct influence on recovery among PwS in Jordan. In terms of cultural background, Jordanian families have intimate interpersonal relationships and many interactions with family members (Abu-Ras, 2003). The findings of the previous studies indicated that collectivistic culture has both a positive and negative impact on the schizophrenia course. However, the negative influence of culture is correlated with more severe stigma against mental ill people and their family relatives when compared with an independent culture. Stigma towards mental illness and unwanted side effects of medication has been reported as the barriers to recovery (Al-Adawi et al., 2002; Nasir & Al-Qutob, 2005).

In recent times, scholars have increasingly focused on the negative effect of schizophrenia on an individual’s personal life, namely, in terms of their family and their work (Mueser et al., 2001). Subsequently, patients who are in recovery are more likely to be obedient in their treatment regime, take their antipsychotic medication and show moderate functioning (Warner, 2009). Those who have been diagnosed as suffering from mental illness will acquire a sense of helplessness if they have to stay in hospital for long periods of time, even if they have been given the latest antipsychotic medication (Park & Sung, 2013). It has been found that learned helplessness is a major challenge in terms of getting patients integrated within their communities. Directing those who have serious mental illnesses, for example, schizophrenia, to manage their psychiatric symptoms and preventing a relapse at the early stages, is an efficient way to treat PwS as it helps in their recovery (Jo, 2009; Shearer, 2009).

Empowerment intervention has been developed to help empower those who have schizophrenia, in a bid to allow them to feel they are a part of the treatment process (Shearer, 2009; Warner, 2009). Empowerment is a construct that links individual strengths and competencies, natural helping systems and proactive behaviours to social policy and social change. In health, empowerment emphasizes increasing one’s sense of one’s ability to participate knowingly in health and healthcare decisions (Rappaport, 1995, 1997). In other words, health empowerment refers to a health pattern of well-being and a relational process that emerges from the recognition of personal and social contextual resources. Moreover, another definition of empowerment emerged from the study conducted by Rappaport (1997) who defined psychological empowerment as ‘the connection between a sense of personal competence, a desire for and a willingness to take action in the public domain’. It is also defined as a process of ‘gaining control over one’s life and influencing the organizational and societal structure in which one lives’. The core features of empowerment include an ability to decision-making power, assertiveness, a feeling that one can make a difference, learning about and expressing anger, not feeling alone, feeling part of a group, understanding that a person has rights, growth and change that is never-ending and self-initiated, increasing one’s positive self-image and overcoming stigma, among others (Slade, 2010).

This process facilitates purposeful participation in the attainment of health goals and the promotion of individual well-being (Shearer, 2009). There has been much discussion regarding the need to empower adult schizophrenics to make informed health decisions and to test interventions targeting empowerment to promote health among them. Empowerment intervention in PwS is an especially important challenge related to recovery in psychiatric health services. However, only a few studies have investigated psychiatric ward interventions to empower patients, improve their prognoses and reduce the risk of relapse. Greater understanding of one’s illness and a more positive attitude towards medication can improve outcomes. Educational interventions that affect patients’ attitudes are likely to have important impacts on psychosocial rehabilitation and/or recovery-oriented services (Hasan, Callaghan, & Lymn, 2015; Slade, 2010; Slade, Amering, & Oades, 2008).

It has been argued that empowerment is a crucial element in the recovery process of patients with schizophrenia, and this is the reason why mental health services try to empower PwS (Park & Sung, 2013). Nevertheless, not much is known about how empowerment can be measured in an operational sense (Warner, 2009). It is likely that PwS will feel quite disempowered, however, there are no studies that have investigated empowerment in these people (Chou et al., 2012). Very few studies have examined outpatient psychiatric interventions that seek to empower PwS, patients to enhance their prognosis and lessen the risk of a relapse. It has been found that when a person has a good understanding of their illness, they are more likely to react in a positive way to medication, thus there is a better chance of recovery (Demoz et al., 2014). However, there have only been a few studies to date that have examined outpatient psychiatric interventions that seek to empower PwS, to enhance their prognosis and to lessen the chance of relapse. It has been argued that the better understanding a person has of their illness, the better attitude they will have towards their illness, and this in turn makes the treatment more successful (Demoz et al., 2014).

Considering the cultural influences of the participants’ beliefs and expectation are imperative to devising nursing intervention, particularly when it is provided in the participants (Sandy, 2016). Awareness of the cultural beliefs of the participants is necessary to understand the participant’s views on the mental illness and their willingness to collaborate with mental health professionals (Diken, 2006). A recent study conducted by Chien, Leung, and Chu (2012), who considered the Chinese family and patients beliefs about schizophrenia and their education needs about illness, reported a highly significant impact of the intervention on the knowledge level and psychological related outcomes. For the sake of this study, the characteristic of PwS in Jordan in terms of literacy level, the content and method of delivery intervention tailored to acknowledge participants culture.

Educational interventions that have a positive effect on the perspective of PwS are very important in terms of the psychosocial rehabilitation of the patient (Berry et al., 2014). There is a very limited number of studies which have investigated the impact of empowerment intervention on PwS. In addition, the format utilized for the delivery of interventions to mentally ill people was demanding. Furthermore, this is the first time that empowerment intervention is used in a developing country such as Jordan. The objective of this study is to investigate how empowerment interventions (nursing interventions) can enhance recovery from schizophrenia.

Methods

This study was a single-blinded randomized controlled trial (RCT) to examine treatment as usual alone with treatment as usual plus an empowerment intervention comprising of booklets and verbal discussion. The trial took place in the mental health outpatient department in Amman, Jordan. These outpatient clinics serve the majority of mentally ill people in Jordan. Ethical approval was provided by the Ministry of Health.

Participants, recruitment, consent and baseline assessment

All of the participants were aged 18 years or above and had been diagnosed with schizophrenia spectrum disorder, based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American Psychiatric Association, 2013). The diagnosis for the objective of the study was reported in the patients’ medical records, held at the outpatient clinic. In Jordan, psychiatric diagnosis is done after a structured interview has taken place between the psychiatrist and people with mental illness, as well as family members. All of the participants in the study had to be capable of reading and writing in both English and Arabic and had to be capable of providing consent to take part in the study. People with mental illness with learning disabilities were excluded from the study, as were those who had an organic mental disorder, or those who substance abused. Typically, patients visit the outpatient clinic on a monthly basis to collect their medications. Patients eligible to participate in this study were identified by the duty doctor responsible for prescribing medication and/or research assistant (RA). Therefore, they were both excluded from taking part in the randomization process to minimize bias. The RA contacted potentially eligible patients to confirm whether or not they met the inclusion criteria and then invited them to participate in the trial. Following an explanation of the purpose of the trial and process of trial involvement, patients were asked whether they would consent to participate. The participants were given 2 weeks to think and ask about the study. Once written consent was obtained, a baseline assessment was undertaken. This included patient socio-demographics.

Randomization

The participants were allocated on a random basis to one of the two groups: treatment as usual, or standard plus empowerment intervention. Each participant was given a number and then another researcher, who did not have any contact with the participants randomly allocated them to a group. A computer was used to generate a random number list to allocate participants to a study group, at a ratio of (1:1), generated. Randomization was implemented using a third remote allocation system. Random list numbers were sent to the independent researcher of the study. Then, the RA contacted the independent researcher when recruiting each participant, to receive an allocation.

The outcome of assessments, both after treatment and in a 3-month follow-up were also done by an independent researcher, who was not aware of which group each participant had been allocated to. The researcher and the participants were told which group the participants belonged to once they had been allocated. The participants were given booklets in sealed envelopes in order to reduce contamination and also to ensure the participants remained anonymous. The primary researcher maintained property of the booklets so as to avoid distribution to other clinics.

Treatment as usual

Each of the four clinics receives funding from the state and the care provided by each of them is similar. Every participant in the study received their usual treatment, which comprised medication and laboratory examinations which were carried out by the mental health teams in the clinics.

Intervention

The utilized intervention was adopted from the patient empowerment intervention for schizophrenia (PEPS); this was a component of comprehensive rehabilitation intervention directed towards PwS (Hwang, Lee, & Gong, 2006). For the purpose of the study, the intervention was revised by one psychiatrist and two psychiatric nurses who had clinical expertise. The intervention consisted of six sessions. Each session was provided weekly. The number of sessions was determined based on the average number of sessions in previous studies conducted through other formats of psychosocial interventions and reported a positive result (Hasan et al., 2015; Ran et al., 2003). The intervention discussed six topics classified in three broad categories: comprehending recovery from an illness, doing and undoing: efforts made for recovery and the route to the best recovery. The method of delivering sessions was through a booklet format supported with face-to-face discussion. The length of the discussions varied on an individual basis and ranged between 20 and 30 minutes.

The intervention content was developed based on the updated psychiatric mental health books and systematic reviews as well as mental health team perspectives (Table 1). The final version of the booklet was reviewed by a small sample of the target population (n = 12), as well as three clinical experts. They examined the content, technical elements and viability. The booklet came in double sided A4 format in order for it to be able to fold into three to enable ease of use; it was printed in colour. Images were provided alongside the text to aid in comprehension of the information. The exact timing for the delivery of the intervention was after collecting medication. The intervention began with a RA welcoming the participants and distributing the booklet. The RA then went through the booklet page by page and at the same time provided practical advice and answered questions. In order to lessen the risk of contamination between the two groups in the study, each participant was given an envelope with a booklet inserted in it, which they could take away with them.

Table 1.

The topics and contents of the empowerment intervention.

Booklet number	Topic	Contents
One	Nature and disease course of schizophrenia; stigma	• Diagnosis of schizophrenia according to DSM-V • Truths and myths about schizophrenia • Symptoms of schizophrenia • How to free oneself from stigma as a schizophrenic patient
Two	Weakness and strength of ability to pursue recovery	• Discussing obstacles to recovery in everyday life • Finding individual strength to achieve recovery • Searching for helpful support system
Three	Challenges to one’s life and things to do with family members	• Plan daily schedule for enhancing individual strengths • Seeking support from family members • Learning how to do housework • Learning how to share experiences with family members
Four	Enhancing communication skills and management of self-care	• Practicing verbal and nonverbal communication in a situation • Maintaining general hygiene on one’s own Practicing daily duties
Five	Drug treatment to improve long-term outcomes and Improve drug adherence and prevent worsening of the illness	• Understanding the importance of continuing with one’s medication • Listing therapeutic effects and side effects of medication • Learning medication adherence strategies • Sharing experiences with different side effects of various antipsychotic drugs • Understanding risks and benefits of every medication • Asking help of family members and health providers
Six	Crisis management	• Stress management skills and strategies • Being aware of serious or life-threatening side effects • Correcting problematic situations

Outcome measures

The outcome measures were completed straight after the intervention, as well as 3 months afterwards. These were done by the psychiatric nurse who was blinded to the group allocation.

Primary outcome measures

The primary outcome used a Modified Learned Helplessness Scale (MLHS; LHS; Kim, 2005; Quinless & Nelson, 1998). A LHS is a self-report questionnaire containing 20 items scored using a 4-point Likert-type scale from ‘strongly agrees’ to ‘strongly disagree’. It is scored from 20 to 80 with a high score indicating individuals’ experiencing higher levels of helplessness. This scale has been used with people with mental illness and Cronbach’s alpha was .890–.906 (Kim, 2005). Cronbach’s alpha coefficients of Arabic translated LHS version was .86, and Content Validity Index (CVI) = 86%. This outcome was chosen to be the primary method as previous studies showed a strong correlation between helplessness level improvement and recovery rate and the influence on empowerment.

Secondary outcome measures

Secondary outcomes were psychiatric symptoms, which were assessed by a positive and negative Syndrome Scale (PANSS), recovery rate was assessed by the Recovery Assessment Scale (RAS) and quality of life rated by Schizophrenia–Quality of Life questionnaire (S-QoL-18) and empowerment level as rated by the Empowerment scale.

PANSS measures 30 schizophrenia symptoms; each clinical symptom is scored from 1 indicating absence of psychopathology to 7 indicating severe psychopathology, with higher scores indicating severe psychiatric symptoms. Internal reliability and criterion-related validity are 0.77 (positive scale) and 0.77 (negative scale) and 0.52 with the Clinical Global Impression scale (CGI; Kay, Opler, & Lindenmayer, 1988).

RAS has 41 items measuring life goal, coping ability, hope and knowledge of support systems. The scale uses a 5-point agreement scale (Giffort, Schmook, Woody, Vollendorf, & Gervain, 1995). Sample items include ‘I have a desire to succeed’ and ‘I can handle it if I get sick again’. A previous study of the scale showed overall scores to have satisfactory reliability and validity in the United States (Corrigan, Giffort, Rashid, Leary, & Okeke, 1999). Cronbach’s alpha coefficients of Arabic translated version of RAS scale was .87, and CVI = 86%.

The S-QoL has 18 evaluating eight dimensions: psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life. The total score ranged from 18 to 90 with a higher score indicating a better quality of life. Cronbach’s alpha is .72–.84 in European countries. Cronbach’s alpha coefficients of Arabic translated version of SQoL was .88 and CVI was 0.86%. The empowerment scale was devised by Rogers, Chamberlin, Ellison, and Crean (1997) and has 28 items with five subscales including, self-esteem, optimism, activism, righteous anger and power. Some items of the scale include ‘I feel powerless most of the time’ and ‘People are limited only by what they think possible’ (Rogers et al., 1997). Cronbach’s alpha coefficients of Arabic translated version of empowerment scale was .85 and CVI was 0.87%.

Analysis

Sample size

The sample size was estimated based on previous research which showed a change in the helplessness score of 2 points post-intervention (Park & Sung, 2013). Taking into consideration a power of 80% and significance level of p < .05, allowing for 10% attrition, deduced from previous studies, we estimated 112 participants would be required.

Statistical analysis

All data were analysed using SPSS Version 23. Analysis was done by intention to treat with the last observation carried forward to handle missing data at post-treatment and 3-month follow-up. Analyses were carried out blind, with the groups known as ‘arm 1’ and ‘arm 2’. Methods of analysis such as Intention to Treat analysis (ITT), per protocol (PP) and ad hoc approaches (imputing worst value in the control group for intervention group and the best value in the intervention group for control group) were used to increase the robustness of and confidence in the study results. In addition, multiple imputation techniques were employed to handle missing data. However, the findings were similar among these approaches. Consequently, the Last Observation Cariied Forward (LOCF) method of handling missing data was used in this study. Demographic data were summarized by frequencies and percentages. Independent samples t-test were used for continuous variables. The mean scores between groups on all outcome measures were compared using an independent sample t-test, as appropriate. To control for type I errors for multi-comparison tests, Bonferroni’s adjustment was used to adjust the level of significance set at baseline for all statistical tests to the 1% level (p < .01). Analysis of variance (ANOVA; between and within) was used to determine whether treatment produced between and within groups and the interactive effects of treatment by time for each outcome.

Results

Baseline characteristics

A total of 179 potential participants were initially approached by the RA to discuss potential participation in the trial. Of these, 112 were identified as meeting the inclusion criteria and were invited to participate in the study. The remaining 67 did not meet the study inclusion criteria for several reasons: having a dual diagnosis (n = 32), 15 PwS had an intellectual disability and schizophrenia diagnosis and five people were illiterate. In addition, 19 participants who expressed an interest in taking part in the study did not return signed consent forms.

Generally, the participants’ age averaged 36.5 years and the majority of the study sample were male. This is consistent with the nature of Jordanian culture: that is, to hide females diagnosed with mental illnesses. Over half of patients attained secondary or a higher level of education. However, most participants were unemployed. There were no significant differences in general characteristics between groups. A total of 112 PwS provided consent and were randomly allocated to empowerment and recovery intervention and treatment as usual (TAU; n = 56) or TAU (n = 56; Figure 1). Baseline characteristics of participants are shown in Table 2. There was no statistically significant difference between the groups on baseline characteristics. The attendance rate for the first three sessions was 100%. However, in session number four, two participants missed the session on the specified time, so their sessions were rescheduled. Moreover, in the remaining session, one patient was not able to attend due to logistical problems and so the session was carried out at a later date. Intervention fidelity was monitored by delivering intervention to participants in the same way and the RA conducted all face-to-face discussions.

Figure 1.

Participants progression throughout different stage of the study.

Table 2.

Demographic characteristics of PwS in two groups.

Characteristics	Empowerment intervention (n = 56)₮		Treatment as usual (n = 56)¥
	Frequency	%	Frequency	%
PwS
Age, years (M, SD)	(37.6, 5.6)		(36.9, 6.3)
⩽20	7	12.5	12	21.4
21–30	12	21.4	11	19.6
31–40	8	14.2	17	30.3
41–50	21	37.5	11	19.6
⩾50	8	14.6	5	8.9
Gender
Male	36	64.2	33	58.9
Female	20	35.7	23	41.1
Education level
Primary school or below	15	26.7	14	25
Secondary school	18	32.1	16	28.6
College or above	23	41.2	26	46.4
Employment status
Employed	16	28.6	18	32.1
Unemployed	40	71.4	38	67.9
Marital status
Married	18	32.1	16	28.5
Single	25	44.6	24	42.8
Divorced	7	12.5	7	12.5
Others	6	10.7	9	16.0
Illness duration in years (M, SD)	7.7 years (4.3)		8.2 years (4.5)
⩽2	16	28.5	13	23.2
3–5	22	39.2	20	35.7
⩾5	18	32.1	23	41.1

M: mean; SD: standard deviation; ₮: interventional (empowerment intervention) group; ¥: treatment as usual (TAU-standard outpatient care); JoD: US$1.4.

Intervention effect on the PwS outcomes

Primary outcomes

Exploration analysis was carried out on the dependent variables at both pre-test and two post-tests in order to investigate the initial assumption for mixed between-within subject ANOVA on tests of normality, linearity, multi-collinearity, univariate and multivariate outliers. The homogeneity of variance showed there was no significant violation of the assumptions (Tabachnick, Fidell, & Osterlind, 2011). The data from the primary and secondary outcome of the PwS revealed there were no statistically significant differences, which is shown in Table 3.

Table 3.

Outcome measure scores at baseline and post-tests results from repeated-measures ANOVA test (group × time) between intervention and treatment as usual.

Instrument	Empowerment intervention (n = 56)₮						Treatment as usual (n = 56)¥						Repeated-measures ANOVA
	Baseline		Post-test 1		Post-test 2		Baseline		Post-test 1		Post-test 2		Time × group	Time	Group
	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	F	F	F
LHS (20–80)^a	69.54	8.95	57.34	7.50	50.68	6.6	70.13	6.52	68.78	6.57	76.86	7.48	181.32***	98.45***	74.53***
PANSS (30–210)^b	87.56	10.45	75.56	11.37	66.02	10.43	86.38	12.58	89.59	15.37	86.64	16.83	64.23***	94.72 ***	37.74***
RAS (26–130)	55.45	7.67	78.36	7.87	88.56	9.65	56.37	6.45	55.73	5.89	56.01	6.34	54.34***	64.78***	78.45***
SQoL (18–90)	47.65	5.78	58.34	4.76	63.43	6.34	48.03	6.65	49.46	5.86	50.50	5.74	39.56 ***	88.78***	26.58***

₮: intervention (empowerment intervention) group; ¥: treatment as usual (standard outpatient care); M: mean; SD: standard deviation; LHS: Learned Helpless Scale; PANSS: Positive and Negative Syndrome Scale; RAS: Recovery Assessment Scale; SQoL: Schizophrenia–Quality of Life; Post-test 1: immediately post-intervention; Post-test 2: 3-month post-intervention.

Possible range of scores of each scale indicated in parenthesis.

***

p < .001.

When making a comparison between the participants in the treatment as usual, those in the empowerment intervention showed statistically significant improvements in LHS scores, both immediately after treatment and also at the 3-month follow-up. Mauchly’s test of sphericity was significant (p < .05); therefore, a Greenhouse Geisser correction for the df value was carried out (Field, 2009). The interaction between the groups in terms of time was also significant for LHS p < .001, univariate eta squared = 0.54 (large effect; Field, 2009). A significant time effect was also shown for LHS (p < .001), univariate eta squared = 0.36 (large effect). Furthermore, the result revealed a significant group effect (treatment) on LHS (p < .001), univariate eta squared = 0.43 (large effect). This means there is improvement in the LHS score during the follow-up period within the empowerment intervention. However, in the treatment as usual, there was a gradual negative change during the same time period.

Secondary outcomes

In terms of the PANSS scores, they revealed a significant reaction between the groups and time (p < .001), univariate eta squared = 0.31 (large effect) and a significant effect with time was revealed in the PANSS scores (p < .001), univariate eta squared = 0.29 (large effect). The results also revealed a significant difference in regards to the group effect (p < .001), univariate eta squared = 0.27 (large effect). These results suggest that taking part in the empowerment intervention is linked to a reduction in the harshness of symptoms at post-treatment and also at 3-month follow-up.

The results also showed there was significant interaction between group and time (p < .001), univariate eta squared = 0.31 (large effect) and significant effect time was revealed on RAS scores (p < .001), univariate eta squared = 0.33 (large effect). The results also revealed a significant difference in regards to the group effect (p < .001), univariate eta squared = 0.21 (large effect). These results suggest that taking part in the Empowerment intervention is linked to an improvement in recovery rate at post-treatment as well as at 3-month follow-up.

The results exhibited there were no statistically significant differences between the intervention and the treatment as usual in the baseline measures linked with SQoL scores. Mauchly’s test of sphericity also proved to be significant (p < .05) and therefore a Greenhouse Geisser correction, for the df value was carried out. The interaction between groups by time was significant for SQoL scores (p < .001), univariate eta squared = 0.34 (large effect). Furthermore, the group (p < .001), univariate eta squared = 0.26 (large effect) and time effect (p < .001), univariate eta squared = 0.35 (large effect) were statistically significant for SQoL outcome.

Interestingly, the findings indicated there was significant interaction between group and time (p < .001), univariate eta squared = 0.27 (large effect) and significant effect time was revealed on empowerment scores (p < .001), univariate eta squared = 0.26 (large effect). The results also revealed a significant difference in regards to the group effect (p < .001), univariate eta squared = 0.18 (large effect). These results suggest that taking part in the empowerment intervention is linked to an improvement in empowerment level at post-treatment, as well as at 3-month follow-up.

Discussion

To the best of our knowledge, this study was the first RCT utilizing a helplessness and recovery empowerment intervention targeted at PwS to promote recovery at a national and an international level. Furthermore, it is the first of such a study to be carried out in the Middle East. Overall, the model presented in Figure 2 explains trial results ‘reduction in helpless and its impact on other measured outcomes at post-test 1 and post-test 2’. In part, the model explains how empowering PwS is associated with a reduction in psychiatric symptoms, improving empowerment levels and improvement in recovery rate. It indicates that internalized stigma moderates the effect of awareness of schizophrenia on the hope and self-esteem of PwS patients. This is consistent with the findings of this study, suggesting that benefits from the psychiatric treatment and rehabilitation interventions are related to the meanings people assign to both their illness and the treatment itself (Pijnenborg, Van Donkersgoed, David, & Aleman, 2013; Tait, Birchwood, & Trower, 2003). Notably, rejecting social and self-stigma among participants may have led to a sense of hope and confidence about the possibility of recovery and changed other negative self-evaluations. This in turn may lead to high engagement in the intervention and treatment and a tendency to use effective coping strategies (i.e. reassurance, persuading or seeking support from others) to deal with schizophrenia symptoms and stressors. These changes may have improved their social contacts. Simply put, the process of accepting and internalizing social stigma changes the way people perceive and feel about themselves and their likelihood to plan and meet their life goals, and consequently leads them to avoid others and experience depression.

Figure 2.

Potential impacts intervention.

This study results revealed that the intervention was effective in reducing feelings of helplessness among participants who received intervention straight after the intervention and 3 months afterwards. These results are in agreement with those obtained in earlier studies (Kim, 2005; Park & Sung, 2013; Warner, 2009). As a result, the study results supported the hypothesis that participants who received intervention would show less helplessness post-intervention immediately and at 3-month follow-up in the hopelessness and recovery of empowerment intervention compared with treatment as usual. In turn, this would improve recovery and quality of life as well as empowerment level. Chronic PwS showed growing feelings of helplessness compared with acute PwS (Lodge, 2010). This finding may be potentially justified in that chronic PwS experience recurrent hospitalization which might be erosive and limit his or her ability to achieve their life plan. They might also be more accepting of prejudices and internalizing it all to themselves, leading to feelings of shame and alienation. A further analysis was carried out to compare the intervention effectiveness on acute and chronic PwS. It demonstrated a significant improvement in the recovery and helplessness outcome among acute and chronic PwS. It seems that the intervention helped PwS manage their condition and provided them the courage to confront stress and stigma. Furthermore, in this study, empowerment modified the way participants perceived their illness, and encouraged them to take more control over negative events and to handle internalized stigma better, which may in turn have led to their improved well-being (i.e. being less stressed and more optimistic).

There are a limited number of studies that have examined the effectiveness of helplessness and recovery empowerment intervention. This renders comparison and contrast hard. On the other hand, studies tested other forms of psychosocial interventions such as psychoeducation in Jordan and demonstrated its effectiveness (Hasan et al., 2015). This study findings confirm that adding such an intervention to standard healthcare in psychiatric clinics is an effectual method to ameliorate the severe symptoms of schizophrenia (Baggaley, 2008; San et al., 2012). A possible explanation for this might be that the intervention instilled accurate information about illness, which might enhance their insight of the illness and help PwS devise coping strategies as well as change their attitudes towards antipsychotic medication (Mui & Huiting, 2015). This might result in creating a low stress environment through being vigilant about stressor triggers, which might have also led to a further reduction in psychiatric symptoms and improved recovery and helplessness levels. Unfortunately, a further study needs to be carried out to measure this intervention effect on insight and medication compliance. The results of this study largely support those of previous studies, showing that an empowerment of PwS was an important factor in encouraging them to continue taking their drug treatment after discharge; it might potentially play a key role in reducing relapse rate in the hopelessness and recovery of empowerment intervention participants immediately after the intervention and at 3-month follow-up. As a result, it possibly reduced helplessness (Suzuki, 2007; Vauth, Kleim, Wirtz, & Corrigan, 2007). A further study is needed to examine the relationships between empowerment intervention on relapse rate, self-esteem and medication compliance.

It was revealed that having knowledge about the illness was the most significant route to patients having a positive attitude, which suggests that adherence focused psychoeducation should be implemented into the everyday care of patients at clinics for better long-term outcomes (Boyer et al., 2012). Non-adherence to antipsychotic medication was noted to be a significant factor in reducing PwS’ self-esteem. Additionally, the knowledge obtained from the intervention ‘empowerment’ enabled them to cope with their psychiatric symptoms, rather than adopting an avoidance coping strategy (Boyer et al., 2012). Another intriguing point is that the empowerment intervention provided social support through better understanding of their illness. Consequently, they changed various home environment ‘stressors’ that may have contributed to further reducing the severity of psychiatric symptoms. Chou et al. (2012) demonstrated that the severity of the psychiatric symptoms is the main factor that negatively affected the QoL and impeded recovery rate among PwS.

What the study adds to the international evidence

The findings of this study are important, as this intervention is the first time this intervention has been tested in Arabic-speaking countries and used an innovative method of delivering intervention. Moreover, this study is the first international or national study to utilize an RCT to examine the effectiveness of an empowerment intervention. Such a study design is generally considered to be the gold standard in comparing and evaluating different treatments (Craig et al., 2011). The design of the study was influenced by a pragmatic approach; the study reflected the ‘real world’ as the research team did not test a specific theory and the findings were meaningful for a clinical setting. In addition, the study was designed and conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement guidance for trials of this nature (Schulz, Altman, & Moher, 2010).

The pragmatic approach allowed for the inclusion of participants that are typical of PwS to be treated and supported in a current clinical practice, which might have maximized the generalizability of the findings. For example, the study did not exclude participants who had only been diagnosed with schizophrenia for a short time, or those who refused to take medication. Although RCT is a robust research design, this study has some weaknesses. First, the research team was not able to report the type of antipsychotic medication because prescribing of medication relies on the preferences of the psychiatrists and lack of the availability of antipsychotic medication in Jordan. This implies that the level of medication does not necessarily relate to the level of illness as a PwS patient could be on a higher dose but also be functioning well. Moreover, psychometric properties of the utilized outcome measures are not established yet.

Conclusion

To the researchers’ knowledge, this study is the first randomized control study that has examined helplessness recovery empowerment intervention, delivered via booklets, both globally and in the Middle East, which has investigated a wide array of outcomes. This format of delivering intervention is less demanding and accessible and more accepted by mentally ill people. This study revealed that the empowerment intervention was superior in decreasing individual helplessness, improving recovery rate, decreasing psychiatric symptoms and improving quality of life. This study has also demonstrated that intervention content and method of its delivery was acceptable and can be easily carried out by psychiatric outpatient clinics. The study revealed the possibility of including empowerment interventions as a part of an inclusive psychosocial intervention.

Footnotes

Acknowledgements

Trial registration: NCT02968667.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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