International Journal of Psychosocial Rehabilitation
Integrated Psychosocial Intervention in
Implications for Patients and Caregivers
(A Study from India)
Selwyn Stanley, MSW, PhD
Reader & Head
Dept. of Social Work,Bishop Heber College
Tiruchirappalli: 620 017.
S. Shwetha, MSW
Psychiatric Social Worker
Sowmanasya Institute of Psychiatric Education & Research
Tiruchirappalli: 620 002.
Stanley S. &
Shwetha, S. (2006).Integrated Psychosocial Intervention in
for Patients and Caregivers.
Rehabilitation. 10 (2), 113-128.
Acknowledgement:: The authors
wish to express their heartfelt gratitude
to Dr. G. Gopalakrishnan, Director Sowmanasya Institute for Psychiatric
Education and Research, Tiruchirappalli, India, for the permission
granted to undertake this study and for the invaluable help rendered at
every stage of the research process.
A comparative pre and post intervention analysis to determine
the extent of change in psychiatric symptomatology in schizophrenic
patients attending a community based rehabilitation programme and the
family burden and perceived quality of life of their caregivers was
undertaken. An integrated intervention package comprising of
pharmacotherapy, psychosocial therapies and spiritual therapy was
provided to the patients and their caregivers. Instruments to assess
the psychiatric status of the patients as well as family burden and
quality of life of their caregivers were administered. Results indicate
significant reduction in patient symptomatology as well as caregiver
burden and enhanced QOL of the caregivers following intervention.
Further, a significant negative correlation between the family burden
and QOL scores of the caregivers was obtained. It is suggested on
the basis of this study that spiritual therapy specific to the
religious orientation of patients combined with pharmacotherapy and
other psychosocial therapies may enhance the effectiveness of
intervention in schizophrenia.
rehabilitation, Family burden of caregivers, Quality of life of
caregivers, Therapeutic intervention.
Indian families have been typically described as often believing in
causes like supernatural forces and therefore seek help from
magico-religious healers observe Srinivasan & Thara (2001). Beliefs
about the causation of schizophrenia could influence the attitudes
patients' families adopt towards the patient and may also influence
their help-seeking behaviour. This is particularly true of rural and
semi-urban populations in India and those hailing from an orthodox and
very religious background who throng religious centers of healing in
search of a desperate cure for mental illness.
Schizophrenia is a severe mental illness, which is stressful not only
for patients, but also for family members. Providing care to family
members dealing with chronic illness may result in feelings of burden
or strain for caregivers that can diminish their quality of life
(Sales, 2003). Numerous studies have demonstrated that family
caregivers of persons with a severe mental illness suffer from
significant stresses, experience moderately high levels of burden, and
often receive inadequate assistance from mental health professionals
(Saunders, 2003). Martens & Addington (2001), observe that family
members are significantly distressed as a result of having a family
member with schizophrenia and Ivarsson et al. (2004) contend that
family caregiver burden is complex and includes several areas such as
activities in daily life, worry and social strain. Effective family
functioning in families with schizophrenia may be influenced by a
variety of psychosocial factors (Saunders, 2003). Family conflict and
family intimacy have been found to reflect the degree of burden or
reward experienced and it is suggested that the family system, as the
context within which the patient exists, be seen as the mediating
environment for caregiving burden and reward (Heru, 2000).
Identifying predictors of family burden in caregivers of patients with
schizophrenia has been the focus of several investigations. Lanzara
(1999), found that disability is the main predictor of family burden
whereas manic and positive symptoms, time spent by the carer with the
patient and carer's social support are less important. Satisfaction
with mental health services is predicted by family burden. Disability
related to work and sexual problems is frequent while social
withdrawal, under activity, lack of participation in household duties
and lack of self-care are less frequent. Family burden is severe in one
third of relatives, mainly in social relationships. Solomon &
Draine (1995), opine that the best set of predictors of burden,
identified by stepwise linear regression, was young patient age,
awareness of patient's suicidal ideation, and family resources. Mc
Donell et al. (2003), found that 39% of the variance in subjective
burden was explained by the severity of stressors related to the
relative's illness and by mediators related to social support and
Lauber et al. (2003), are of the view that the most important predictor
of burden is burden in the relationship between caregiver and the
affected representing the changes in the relationship occurring in
acute illness. Threats, nuisances, time spent with the affected, and
burden due to restricted social life and leisure activities were
additional predictors. Winefield and Harvey (1994), observe that burden
in the sense of interference in their daily lives was most marked for
those caregivers who were in high contact with the patients. Stengard
et al. (2000), found that caregivers were more likely to be
dissatisfied with the situation if they lived with the patient and if
the patient's functional state was poor or the patient's use of
services, particularly medication and rehabilitation was low.
Psychological well being of carers is affected by the dimensions of
perceived burden (Madianos et al., 2004). Psychological impairment was
related with high levels of burden and negative family atmosphere.
Previous admissions and duration of illness were also found to predict
burden. Winefield and Harvey (1993), found that caregiver psychological
distress was high and the level of behavioral disturbance in the
sufferer was found to contribute to caregiver distress after
controlling for the caregiver's age, sex, and social supports. In
general, changes in the parents' burden level are closely
interconnected with the illness curve of the patients, and Jungbauer et
al. (2003), observe that parents of continuously and severely affected
patients are overloaded with their long-term caring tasks.
It is also seen that parents and spouses perceive the caregiver burden
differently, although there are some apparent similarities (Lauber et
al., 2003). Jungbauer et al. (2004), hold that the spouses not only
face illness-specific burdens but also burdens resulting from their
partnership and family roles. The chronic burden of everyday living can
profoundly reduce the quality of life and the subject's satisfaction
with the partnership.
Thornicroft et al. (2004), found that low quality of life in
schizophrenic patients was associated with: anxiety, depression,
psychotic symptoms, more previous psychiatric admissions, alcohol
abuse, having no reliable friends nor daily contact with family, being
unemployed, and having few leisure activities. The most frequently
occurring unmet needs among the patients were: daytime activities,
company and intimate relationships, psychotic symptoms, psychological
distress, and lack of information. The most common worries of relatives
were about the patient's health, and their own future, safety and
In a study from Germany, Angermeyer et al. (2000), report that more
than half the participants expressed the need for more support and
complained of not having enough opportunities to relieve their burden.
Hence there is a distinct need to understand the extent and nature of
burden experienced by the caregivers of schizophrenics and to initiate
measures during intervention to enhance their quality of life.
Though there are several crossectional studies in the literature that
have investigated family burden and quality of life in caregivers of
patients with schizophrenia, it is seen that not many prospective
studies have investigated change in these variables prior to and after
intervention and such studies are woefully inadequate in the Indian
context. This study attempts to address this lacuna and is a
comparative pre and post intervention analysis that seeks to determine
the extent of change in psychiatric symptomatology in schizophrenic
patients attending a community based rehabilitation programme and the
family burden and perceived quality of life of their caregivers.
Material and Method
1. To portray the
socio-demographic and clinical profile of patients with schizophrenia
as well as their primary caregivers.
2. To assess the psychiatric status of the patients
at admission and at first follow up.
3. To assess the caregivers of patients with
schizophrenia before and after psychosocial intervention with regard to
the following subject dimensions:
a. Family burden
b. Quality of life (QOL).
4. To bring out
correlations if any between the subject dimensions.
5. To ascertain if the patients as well as their
caregivers show any differences on these subject dimensions based on
The study was conducted at the community based care center, Gunaseelam,
in TamilNadu, a southern state of India. The rehabilitation center is
attached to a Hindu temple named after its presiding diety Prasanna
Venkatachalapathy Perumal. The site is a known place for
religious healing of the mentally ill for the past 200 years. Now a
modified integrated treatment approach is offered in the temple
premises for schizophrenic patients. It is a blend of traditional
temple rituals and modern psychiatric intervention involving
pharmacotherapy and psychosocial therapies. The center has 12 beds, and
provides inpatient services exclusively for schizophrenia patients. The
treatment follows an integrated approach which includes
pharmacotherapy, psycho education and spiritual therapy. Professional
services are provided by the Sowmanasya Hospital and Institute of
Psychiatry, Trichy free of cost.
Components of Integrated Interviention
I. Intervention for the patients
b. Individual psychotherapy
Supportive therapy, motivation,
counselling, psychoeducation, relapse prevention, CBT, if required by
c. Group therapy
Play therapy, movement therapy,
Recreational therapy Art therapy.
d. Occupational therapy
Paper cover making, cleaning tulsi
Attention and concentration exercises
e. Spiritual therapy
Pradhakshanam (circling around the
deity in a clock wise manner twice a day).
Attending four-kaala pooja (Performing ritualistic worship four times a
Splashing holy water on their faces twice a day.
II. Interventions for the caregivers
a. Individual psychotherapy
Supportive therapy, psychoeducation,
b. Group therapy
Group family therapy, Group psychoeducation, and Raja yoga meditation.
The stay period is for a minimum of 48 days to a maximum of 90 days for
the patients and their caregivers.
Professional team members: Psychiatrist, psychiatric social workers,
occupational therapist, Nurses.
This is a quasi-experimental study since no control group has been
deployed nor have subjects been assigned randomly to an experimental
and a control group as in a true experimental study (Judd & Kenny,
1981). It uses a single subject design comprising of a group of
schizophrenia patients as well as their caregivers and compares
pre-intervention baseline data with that following intervention in both
groups. The attempt has been to bring out changes if any in the mental
health status of the patients as well as the burden and QOL of their
caregivers following intervention.
Selection of Respondents
Data was collected from thirty consecutive patients and their
caregivers based on the following criteria:
Inclusion criteria for the patients
1. Patients should have been diagnosed schizophrenia
(F20) (using ICD – 10 Diagnostic criteria, WHO 1992)
2. Patients should be above 20 years of age.
3. Patients should be co-operative for data
Inclusion criteria for the caregivers
1. An adult aged 20 years or more
2. He / she should be of first or second – degree
relationship to the patient.
3. Should be the attendant of the patient during the
entire stay in the community care center and also should care for the
patient after discharge.
4. Willing to co-operate and provide consent for the
The exclusion criteria for the caregivers and patients
1. Caregiver should be free from psychiatric or
physical disorder which might interfere with the care of patients and
his / her co- operation during interviews.
2. Any other co- morbid psychiatric diagnosis in the
patient like dementia, OCD, Substance abuse (excluding tobacco use).
1. Family Burden Scale by Pai and Kapur (1983).
2. Perceived Quality of Life Scale by Patrick et al.,
3. Positive and Negative Syndrome Scale (PANSS) by
4. Self-prepared interview schedule to elicit
socio-demographic data and clinical particulars.
The PANSS was administered to the patients for assessment of
symptomatology and the remaining instruments to the caregivers. All
instruments were administered twice; first at the time of admission and
later after intervention during the first follow up contact 30 days
after discharge from the center.
General Background of the Caregivers
The majority of the caregivers were female (53.3%) and their age ranged
from 23 to 75 years with a mean age of 54.9 years. While the majority
of them were parents (76.7%), 16.7 per cent of the caregivers were
spouses and the remaining (6.6%) were siblings of the patient. The
majority of the caregivers were married (70%) and had availed of basic
school level education. Their mean income per month was
Profile of the Patients:
The age of the patients ranged from 21 to 50 yrs with a mean age of
32.7 years. The majority of them were female (53.3%) and were unmarried
(66.7%) and had availed of school education. Seventy per cent of them
were not employed while the remaining were earning and had a mean
income of Rs. 533.30 per month. The majority of them hailed from
nuclear families (76.7%) and had a mean family size of 3.8. Half of
them belonged to the first two ordinal positions in their family. All
of them had a F20 diagnosis and the majority were said to have the
illness for 5 to 10 years (63.3 %). The majority of them manifested the
disorder before the age of 22 and sixty per cent reported being treated
for a duration up to 5 yrs. The majority (70%) reported irregular
treatment and had a history of multiple hospitalizations prior to their
admission at Gunaseelam. For 46.7% of them this was the first instance
Results & Discussion
Data analysis was done by using SPSS (Ver. 10.0). The data was
subjected to statistical procedures such as t- test, ANOVA, Scheffe
procedure and Karl Pearson’s correlation.
Psychiatric Symptomatology in the Patient
The data in Table No. 1 reveals a statistically significant improvement
in terms of psychiatric symptomatology at first follow up. This is
indicated by the considerable reduction in mean scores obtained on all
the sub-dimensions of the PANSS as seen in the table. The efficacy of
the intervention carried out is vindicated by the t-values, which show
a significant difference prior to and after intervention. Magliano et
al., (2005), have found that the provision of psycho educational
intervention was associated with a statistically significant
improvement in patients symptoms. Similarly a study from China has
found that family education on schizophrenia was effective in improving
knowledge and promoting improvement in patients’ symptoms and
functioning (Zheng Li & David Arthur, 2005).
Family Burden & Quality of Life of the Caregivers
The figures in Table No. 2 show that there is a statistically
significant difference in the status of the caregivers before and after
intervention vis-à-vis the burden experienced by them as well as
their quality of life as revealed by the t-test. Further it is observed
that there is a reduction in the mean score values on the overall
burden score as well as all its sub-dimensions following intervention,
at first follow up. In a similar study Moller-Leimkuhler (2005), found
that though there was a considerable level of burden in most of the
relatives at 1-year follow-up, a significant reduction in objective and
subjective burden was seen while compared to their baseline status. The
effectiveness of intervention in schizophrenic patients has been
demonstrated in a study by Magliano et al., (2005), who found that the
provision of psycho educational intervention was associated with a
statistically significant improvement in family burden and coping
strategies. It is also seen in Table No.2 that the mean scores have
increased on the overall quality of life score and its three
sub-dimensions, indicating an enhanced quality of life in the
caregivers after intervention. This finding is in consonance with that
of Moller-Leimkuhler (2005), who found significant improvements in
well-being, self-rated symptoms and subjective quality of life in
two-thirds of the relatives of patients with schizophrenia. Foldemo et
al., (2005) have found that parents of schizophrenic patients were
significantly less satisfied with their overall quality of life.
Chadzynska (2003), who assessed quality of life in schizophrenic
patients as well as their caregivers, found that both have a tendency
to evaluate QOL similarly.
Analysis by Gender of the Patient
The next analysis was done by computing ANOVA values for the caregivers
based on the gender of the patients before and after intervention.
It is seen in Table No. 3 that the F values show a statistically
significant difference on the overall family burden score of the
caregivers as well as their overall quality of life. Statistically
significant differences are also seen in terms of all the
sub-dimensions of both these variables except for the social component
of the QOL scale. However, Alptekin et al. (2004) did not obtain
significantly different quality of life scores between relatives
of patients and those of control subjects, but found that quality of
life of patients was negatively correlated with the severity of their
psychopathology and the extrapyramidal side effects induced by
antipsychotic drugs .
Following the ANOVA, the data was further subjected to posthoc Scheffe
analysis to ascertain if there were significant differences for
caregiver scores based on the gender of the patients before and after
intervention and these results are posted in Table No. 4.
The results in Table No. 4 reveal that there is a highly significant
statistical difference for the overall family burden scores of the
caregivers of both male and female patients before and after
intervention. This significant difference is manifested for all the
sub-dimensions of the family burden scale except with regard to
financial burden where the before and after scores for both the sexes
of the patients is not statistically significant. Similarly while a
significant difference is seen for female patients before and after
intervention in terms of family leisure, the same is not the case for
the caregivers looking after male patients. It is important to note
that the mean score difference (I – J) for the overall family burden
score as well as all its sub-dimensions is positive for both male and
female patients. This indicates that the scores prior to intervention
(I) were higher than those following intervention (J). The reduced J
values point to a diminishing family burden on all sub-dimensions in
the caregivers following intervention regardless of the gender of the
patient. Similarly the mean score difference (I – J) values for the
overall QOL score and all its sub-dimensions is negative for both male
and female patients, indicating that scores prior to intervention (I)
were lower than those following intervention (J) thus showing enhanced
QOL status in the caregivers following intervention regardless of the
gender of the patient.
When caregivers were compared with regard to their mean FB and QOL
scores, it was seen that those caring for female patients scored higher
on both these dimensions both before and after intervention (Table No.
5). Though this appears paradoxical, it indicates that though
caregivers of female patients experience greater burden, they also
manifest better quality of life than those caring for male patients.
Consistent with this study, Winefield and Harvey (1993), also found
that those caring for female sufferers reported greater distress than
those caring for males. Similarly, Thornicroft et al. (2002) did not
find support for their hypothesis that caregivers of male patients will
show higher rates of psychological distress, and higher scores for
'supervision' and 'urging' than caregivers of female patients.
Analysis by Gender of the Caregiver
A similar analysis was done by computing ANOVA values and Scheffe
analysis, this time based on the gender of the caregivers and the
results are tabulated in Table No. 6.
Comparison of data based on the gender of the caregivers before and
after intervention reveals a highly significant statistical difference
among all four groups in terms of their overall family burden as well
as QOL scores. A similar difference is seen with regard to all the
sub-dimensions of both scales except for financial burden and the
social domain of QOL. While the ANOVA values are based on mean score
comparison of the four groups studied, the Scheffe results helps to
identify the precise status of the caregivers based on their gender
before and after intervention.
It is seen that there is a highly significant statistical difference
for both male and female caregivers before and after intervention
(Table No. 7). This difference is also seen with regard to all the
sub-dimensions of the family burden scale except for financial burden.
In terms of the overall QOL score, while female caregivers show a
significant difference before and after intervention, the same is not
observed for male caregivers. Further while female caregivers show a
significant difference before and after intervention on the physical
domain of QOL, no such differences are seen on the remaining
sub-dimensions of QOL for both male and female caregivers. It is also
to be noted that the mean difference values (I – J) for the overall
family burden score as well as its sub-dimensions is positive whereas
it is negative for the overall QOL score and its sub-domains. This
indicates reduced family burden and enhanced QOL following intervention
for both male and female caregivers.
Table No. 8
INTERCORRELATIONS AMONG SUBJECT DIMENSIONS
FB OV QOL OV PS
NS GP AN
.29 -.07 .03
-.42* 1.00 -.04
-.06 .07 -.05
*Correlation is significant at the 0.05 level (2-tailed).
LEGEND: FB OV- Family burden overall score, QOL OV-Quality of life
overall score, PS-Positive symptoms, NS-Negative symptoms, GP-General
psychopathology, AN-Anergia, TD-Thought disturbance, ACT-Activation,
PAR-Paranoid symptoms, DEP-Depression.
The correlation values plotted in Table No. 8 show a significant
negative correlation between the overall family burden and overall QOL
scores. Though a cause-effect relationship cannot be interpreted on the
basis of this, it indicates that increase in one domain adversely
impacts the other and both seem to mutually influence one another. A
recent study by Foldemo et al. (2005), have also found a correlation
between lower overall quality of life and higher perceived burden in
parents of schizophrenic patients. It is also important to note
that the overall FB and QOL scores did not enter into a significant
relationship with any of the dimensions of the PANSS. This is contrary
to the finding of Hamada et al., (2003) who found that psychotic
symptoms of schizophrenic patients were closely related to the mental
state and QOL of their families. The lack of correlation seen in this
study between psychiatric symptomatology of the patient and the FB and
QOL scores of their caregivers perhaps indicates that both FB and QOL
are complex variables not determined exclusively by the psychiatric
status of the patient but by several other factors as suggested by
previous authors (e.g. Saunders, 2003; Ivarsson et al., 2004). While no
correlations were obtained in this study between the PANSS scores and
the FB and QOL status of their caregivers, another study by (Karow ,
2005), which also used the PANSS, found that anxiety and depression in
schizophrenic patients correlated with their own QOL scores during and
Implecations for Therapeutic Intervention
Caregiver burden and burnout are important, prevalent, and preventable.
Physicians aware of the symptoms and signs can better assess, identify,
prevent, and intervene in these situations. Such efforts result in
improved quality of life for both patients and their loved ones (Kasuya
et al., 2000). Early intervention could result in reduction in
morbidity and better quality of life for the patients and their
families. This study has revealed that an integrated therapeutic
approach consisting of components such as pharmacotherapy, psychosocial
therapies and spiritual therapy is successful in enhancing mental
health status of patients with schizophrenia besides reduction of
family burden and improved quality of life in their caregivers. A
decade ago, Tarrier (1996), argued that a comprehensive and holistic
approach to care in schizophrenia that combines, and continually
refines, pharmacological and psychosocial interventions is required and
that high-quality care and clinical management need to be provided by a
partnership between pharmacological; and psychosocial interventions. He
emphasized that psychosocial interventions can provide patients and
their carers with skills that both increase the patient's resilience,
and empower the patient and carer to forge a partnership with
clinicians to define high-quality care. There is considerable evidence
to emphasize the importance of combining drug therapy with outpatient
psychotherapy, psychotherapeutic management, and psychosocial programs
May (1976). Drug and psychosocial intervention is indicated as part of
tertiary prevention to prevent further disability in the illness
observe Lee et al. (2005).
Psychiatric rehabilitation for schizophrenia involves utilizing
psychosocial interventions to assist persons with the illness to attain
their highest level of independent functioning, strongest level of
symptom control, and greatest level of subjective life satisfaction
(Glynn, 2003). Psychotherapeutic intervention in schizophrenia should
be goal-directed and aimed particularly at developing and promoting
social and occupational skills and at eliciting cooperation with
appropriate drug treatment and monitoring its progress May (1976).
Pekkal & Merinder (2004), observe that psycho education approaches
are useful as part of the treatment programme for people with
schizophrenia and the fact that these interventions are brief and
inexpensive should make them attractive. Further, psychosocial
interventions decrease the frequency of relapse, encourage compliance
with medication, improve general social impairment and the levels of
expressed emotions within the family when compared to standard care
(Pharoah et al., 2004). When relatives of patients with schizophrenia
are able to improve their coping strategies, it is possible for burden
to be reduced. This points to the necessity to provide families of
chronic psychotic patients with psychoeducational interventions
emphasizing the adoption of an effective coping style (Magliano et al.,
Psychoeducation programs for caregivers need to focus on empathic
engagement, education, ongoing support, better access to clinical
resources, social network enhancement, and increased problem-solving,
coping and communication skills. Thorup et al. (2005), in a recent
study which adopted an integrated intervention modality conclude that
the integrated approach is crucial, since, many aspects of the
integrated treatment contributed to the reduction of both negative and
psychotic symptoms in their sample. While a combination of
pharmacotherapy and psychosocial procedures has been routinely used
with schizophrenic patients and their caregivers, it is suggested on
the basis of this study that they may stand to benefit by also
including elements of spiritual therapy specific to their religious
orientation during intervention.
Limitations of the Study
While this study establishes the efficacy of an integrated treatment
modality, the data do not reveal the extent to which its components
(pharmacotherapy, psychosocial intervention or spiritual aspects)
individually have contributed to the changes seen in patients as well
as their caregivers. The absence of a control group is yet another
limitation against which the findings need to be viewed. Respondents of
this study professed a faith in Hinduism and approached the Gunaseelam
center owing to the ‘healing powers’ traditionally attributed to the
diety there and as such those belonging to other religious faiths have
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