The International Journal of Psychosocial Rehabilitation

Experienced Long-Term Benefits Of Group Psychoeducation Among Forensic and Challenging Non-Forensic Patients with Schizophrenia
 
   
Kati Aho-Mustonen, M.A.
 University of Joensuu, Department of Psychology
, P.O. Box  111, FIN-80101
 Joensuu, Finland
Contact: email: kati.aho-mustonen@joensuu.fi

 
Raili Miettinen, M.A.
 
University of Kuopio
Department of Forensic Psychiatry
 
Niuvanniemi Hospital, 70240
 
Kuopio, Finland
 
Hannu Räty, PhD
 University of Joensuu
 Department of Psychology
 P.O. Box  111, FIN-80101
 Joensuu, Finland

 
Tero Timonen, PhD
 University of Joensuu
Department of Psychology
 P.O. Box  111, FIN-80101
 Joensuu, Finland

 
 
Citation:
Aho-Mustonen K, Miettinen R, Räty H & Timonen T. (2009). Experienced Long-Term Benefits Of Group Psychoeducation Among
 Forensic and Challenging Non-Forensic Patients with Schizophrenia.
 International Journal of Psychosocial Rehabilitation. Vol 14(1).  51-63
 


Abstract
This study examined the long-term benefits experienced in a brief group psychoeducation pilot program among forensic and challenging non-forensic patients with schizophrenia in a forensic hospital setting. Data was obtained by semistructured thematic interviews with six long-term schizophrenia patients who attended an eight-time pilot psychoeducation group four years earlier at the Niuvanniemi Hospital in Kuopio, Finland. Using Antonovsky’s Sense of Coherence Theory as a theoretical framework, deductive content analysis was used to analyze the data. Participants experienced benefits from psychoeducation especially in regard to learning new information about the illness and reflecting it to their own situation. Participants also experienced a sense of “shared fate” and noticed that they were not alone in their problems. The aim of providing new strategies for stress management and coping with their illness was not sufficiently fulfilled.
Key words: group psychoeducation, schizophrenia, forensic setting, Sense of Coherence Theory


Introduction
The main principle of psychoeducation is that everyone has the right to receive information about the illness and treatment in order to take more active role in relation to the illness instead of being a passive recipient of care (Cross & Kirby, 2001; Deegan, 1996; McGorry and Edwards, 1997; Mueser et al., 2002). Schizophrenia patients sometimes know very little about their diagnosis despite long-term illness (Hornung et al., 1996). Patients usually want information about their illness, and information should also be provided to those patients who have suffered from schizophrenia a long time (Chien et al., 2001; Wiersma et al. 1998). It has been shown that even quite brief interventions can lead to functional improvements in patients with persistent psychiatric disorders (e.g. Goldman & Quinn, 1988). Chaplin and Timehin (2002) have concluded in their four-year follow-up of a patient education trial concerning tardive dyskinesia that patients can retain a small but significant amount of information several years after an intervention.  Psychoeducation also constitutes a foundation for more comprehensive and individualized treatment forms for schizophrenia patients (Bäuml et al., 2006; Mueser et al., 2002). Psychoeducation can be regarded as a specific form of psychotherapy (Bäuml et al., 2006) but as Klimitz (2006) has pointed out, if psychoeducation is seen only within a deficit model of illness and regarded as merely compliance training, people may only learn to accept the illness; from the standpoint of recovery psychoeducation can, then, not be regarded as psychotherapy.
 
Sibitz et al. (2007) have recently studied the perspectives of non-forensic schizophrenia patients concerning psychoeducation groups and found that participants specifically emphasize the information received, reflections on the new information about the illness and life, exchanging information with other patients, and learning that they are not alone in their situation, as positive experiences in group psychoeducation.
 
It is recommended that structured psychosocial group interventions also be integrated into the treatment of forensic patients, i.e. offenders with psychiatric illness; psychoeducation is nowadays considered an important component in the comprehensive treatment of these patients (Cross & Kirby, 2001; Duncan et al., 2006). Schizophrenia patients in forensic psychiatry are often hospitalized for many years and the treatment poses many challenges as a result of the severity of the patients’ illness, the often persistent symptomalogy, and many related problems, such as aggressive behaviour. Individualized treatment programs with individually adapted components are needed to target the problems of different kind of forensic patients (Hodgins, 2002). Cross and Kirby (2001) have postulated that in forensic settings many patients feel quite hopeless about the prospect of change, and the main purpose of psychoeducation is therefore to combat stigma, and help forensic patients  take more responsibility for their own care and thus live more meaningful lives. The effectiveness of patient psychoeducation has only rarely been studied among forensic schizophrenia patients (see Aho-Mustonen et al., 2008; Jennings et al., 2002).
 
Recovery can be conceptualized as an attitude or life orientation (Resnick et al., 2005), and although forensic patients are often treated differently than other patients and may have limited opportunities for recovery (see Porporinio & Motiuk, 1995), a recovery orientation to psychiatric illnesses has also recently been adopted in the field of forensic psychiatry (see for example Barsky & West, 2007).  Maintaining and instilling hope is an essential feature in the recovery process of the people with severe psychiatric illnesses (Byrne et al., 1994; Clayton & Tse, 2003; Coleman, 1999; Czuchta & Johnson, 1998;   Kelly & Gamble, 2005; Kirkpatrick et al. 1995; Kylmä et al., 2006; McCann, 2002; Spaniol, 2008). Interventions in psychiatric settings can serve  as recovery goals directed towards persons with psychiatric illness, for example, in terms of social and instrumental support, learning and practicing coping strategies to manage their illness and achieving individual goals, and supporting the self-efficacy and self-esteem of the patients (Corrigan, 2003; Mueser et al., 2002; Mueser et al., 2006). For example Anderson et al. (2001) have earlier presented a recovery oriented brief psychoeducational group therapy program for the dually diagnosed patients in inpatient and residential settings.
 
The present study adopted the view that recovery from psychiatric illness is a process of taking back control and living a satisfying life despite of the illness, whereas wellness can be experienced in spite of symptoms, and at any point of the process of recovery (Anthony, 1993; Deegan, 1996; Hutchinson et al., 2006; Kelly & Gamble, 2005; Mullen 1986; Spaniol et al., 2002; Spaniol, 2008; Thornton, 2000). Feeling that one has no control over one’s illness can cause hopelessness and eventually lead a person to abandon responsibility and active coping strategies; hence, this has a significant role in the efficacy of treatment and rehabilitation, and the long-term course and outcome of schizophrenia (Birchwood et al., 1993; Deegan, 1996; Hoffmann, Kupper & Kunz, 2000). It is important that interventions aimed at recovering from mental illness emphasize a hope-promoting environment, processes and strategies such as acceptance of the illness (Hatfield & Lefley, 1993); access to objective information and education (Kirkpatrick et al. 1995; McCann, 2002); viewing persons with psychiatric illness as people, increasing their dignity, self-esteem, self-efficacy, and self-worth, and promoting meaning, mastery and motivation (Coleman, 1999; Kirkpatrick et al., 1995; McCann, 2002; Snyder et al., 2000). It is also important to validate patients’ coping strategies, experiences, and help them with problem-solving, illness management and self-management (Kirkpatrick et al., 1995; Snyder et al., 2000).
 
Coffey (2006) has pointed out that we still do not know much of the experiences of people who use forensic mental health services. The present study was the pilot phase of larger study of the effectiveness of group psychoeducation among forensic patients and the results have been utilized in designing a larger controlled study about the efficacy of group psychoeducation among these patients. The present study sought to examine experiences concerning benefits of group psychoeducation four years after the intervention from a participant perspective. The study questions were: 1) what kind of recollections do the participants have concerning the psyhoeducation group they had attended four years earlier and 2) what are the experienced long-term benefits of group psychoeducation program that participants express and attach to their group experience.
 
Theoretical framework
Landsverk and Kane (1998) have postulated that the processes that result in an effective outcome in psychoeducation are still unknown and therefore proposed the Sense of Coherence Theory developed by Antonovsky (1979, 1987) as a potentially useful framework for conceptualizing the effectiveness of comprehensive psychoeducational programs. They have also recommended that psychoeducation programs should be aimed at schizophrenia patients with persistent illness in institutional settings, since in this context intentionally modified changes in SOC may be possible.
 
According to Antonovsky (1987), individuals move back and forth on a health-disease continuum through life; he calls this orientation the salutogenic model of health. Of major importance in determining a person’s relative position on this continuum is his/her Sense of Coherence (SOC). The sense of coherence construct relates to how individuals assess and cope with stressful situations; the sound management of stressors, explained by Antonovsky, is salutogenesis. The three elements of the SOC are: (1) Comprehensibility – which refers to the cognitive controllability of one’s environment, that the world is interpreted as rational, understandable, structured, ordered, consistent and predictable; (2) Manageability - the extent to which individuals believe they have personal access to adequate resources for coping with challenges, demands or problems in the environment; (3) Meaningfulness - the subjective feeling that life makes sense and that at least some parts of our life are worthy of commitment and engagement. Meaningfulness can also be considered as an emotional component of the SOC (Antonovsky, 1987).
 
Landsverk and Kane (1998) have proposed that an effective psychoeducational model encompasses the three main components contributing to SOC, and in this way psychoeducation works to maintain and enhance an individual’s sense of coherence. Bengtsson-Tops and Hansson (2001) have also suggested that the salutogenic perspective might contribute to well-being among patients with schizophrenia in many advantageous ways. Therefore Antonovsky’s theory was applied as a theoretical tool in the present study for studying the experienced benefits of group psychoeducation for schizophrenia patients.
 
The compatibility of the SOC theory with psychoeducation and the treatment of schizophrenia concerns the relationships between stress, health and coping. Schizophrenic disorders are nowadays understood on the basis of the vulnerability/stress model of mental disorders, first time proposed by Zubin & Spring (1977). In treating schizophrenia a fundamental aim is to reduce vulnerability to life stress and chronic symptom recurrence, as, for example, Nuechterlein & Dawson (1984), have postulated. Since patients in this study suffered from a difficult, long-term illness with persistent symptoms, the salutogenic orientation also seemed relevant in this context. Thus, the goals of the intervention were not to find a cure for the illness, but to improve the patients’ situation and move closer towards positive end of the health-disease continuum. The benefits of psychoeducation have also been postulated to be largely due to non-specific treatment factors (e.g. social support and facilitation and promotion of a shared fate and hope) than due to specific active therapeutic ingredients (Ascher-Svanum & Whitesel, 1999; Bäuml et al., 2006; Sibitz et al., 2007). The SOC theory with its three components is therefore conceptually feasible as it captures both the possible specific and non-specific experienced effective aspects of group psychoeducation.
 
Method
Participants in the present study were 4 male forensic patients, i.e. mentally disordered offenders who had found to lack criminal responsibility for crimes committed and instead admitted to an involuntary psychiatric treatment, and 2 difficult to treat or dangerous non-forensic long-term patients, who met the DSM-IV criteria (American Psychiatric Association, 1994) for a primary diagnosis of schizophrenia, and who had attended the psychoeducation pilot group four years earlier. Also the non-forensic patients in the present study were in involuntary treatment. The pilot intervention was conducted in summer 2001 at the Niuvanniemi Forensic Mental Hospital in Kuopio, Finland. 5 of the 7 patients who initially participated in the intervention were still hospitalized at Niuvanniemi Hospital, and 2 were treated in psychiatric rehabilitation homes. One participant who was no longer hospitalized was not allowed to be interviewed due to his psychiatric state at that time. Participants had severe illness, and at the time of pilot intervention they had been hospitalized in Niuvanniemi Hospital continuously on average over seven years. The mean age of the group was 39.2 years (SD=5.8 years), and the mean GAF, assessed by the doctor in charge of each participants care, was 35.5 (SD=8.5). Clinical characteristics of the group participants at the time of pilot intervention in 2001 are presented in Table 1.
 
Table 1. Clinical characteristics of the group participants  at the time of pilot intervention in 2001.
 
Participant
 
Age
Current treatment started  
Admission status
 
Primary diagnosis
 
Substance abuse
 
Personality disorder
Aaro 45 1986 Forensic patient/
Attempted homicide
Other schizophrenia Alcohol dependence Yes
Samuel 34 1995 Forensic patient/
Aggravated robbery
Undifferentiated schizophrenia Multiple drugs dependence No
Juha 31 1995 Difficult to treat patient/
Violence
Hebephrenic schizophrenia No No
Leo 44 1998 Difficult to treat patient/
Aggressiveness
Hebephrenic schizophrenia Multiple drugs dependence No
Tatu 38 1988 Forensic patient/
Attempted homicide
Undifferentiated schizophtneia Alcohol dependence Yes
Ilkka 43 2000 Forensic patient/
Attempted homicide
Undifferentiated schizophrenia Alcohol dependence Yes

 
The eight-time psychoeducational program used in pilot study was adapted and modified from Ascher-Svanum and Krause’s (1991) “Psychoeducational Groups for patients with Schizophrenia”. The group intervention goals sought to provide information about schizophrenia and coping with the illness. Maintaining and instilling hope was emphasized, and sharing one’s thoughts and group discussion were encouraged. Topics covered in the group sessions included: orientation, definition of schizophrenia and common symptoms, diagnosis and etiology of schizophrenia, course of illness, outcome of schizophrenia and warning signs of relapse, causes of schizophrenia, stress-vulnerability model and the influence of stress, substance abuse in schizophrenia, antipsychotic medication, treatment of schizophrenia, and legal issues. In addition program contained cognitive-behavioral elements, and participants were, for example, assigned homework between group sessions. A normalizing rationale to explain symptom emergence in schizophrenia was used. The group met once a week and the sessions were 45-60 minutes long. The sessions were conducted by two psychologists (the first and second authors of this article). The intervention group utilized a leader manual.
 
The follow-up data was obtained by semistructured individual thematic interviews which contained questions about the participants’ recollections and experiences of the intervention group four years earlier. The participants were first asked to describe in their own words what they could recall from the group. Then complementary thematic interviews were conducted, where more specific questions about their experiences and memories of the group were asked. Interviews were conducted by the first author during the summer of 2005 and were 45-90 minutes long. All but one was audiotaped. Because one participant refused permission to audiotape the interview, his interview was conducted by making extensive notes.
 
The interviews were transcribed verbatim.  In the analyses deductive content analysis, where the structure of the analysis is based on previous knowledge (see Elo & Kyngäs, 2008), was applied. The three major categories were derived from Antonovsky’s Sense of Coherence Theory. The interviews were read and reread by the first author and the expressed benefits were extracted from the text and classified under the three main components of SOC. The categories captured the experiences of the participants very well, as they could be seen to represent a wide range of possible aspects of the intervention (cognitive, behavioral, emotional). Although in previous research comprehensibility has sometimes been seen as a cognitive, manageability as a behavioral, and meaningfulness as a spiritual and emotional component of SOC (see, e.g., Rabin et al., 2005), there is some overlap between categories. For example, in the present study “gaining information” could be categorized to be an experienced benefit in terms of both comprehensibility (more understanding about the illness) or manageability (information as a resource to cope better). Gaining information or understaning were categorized under comprehensibility but if the answer referred more to new skills and behavioral aspects, for example, “learning to search for new information” it was categorized under manageability. Citations from the interviews were used to increase the reliability of the findings (see Coffey, 2006; Elo & Kyngäs, 2008; Graneheim & Lundman, 2004).
 
Ethical considerations
Ethical approval for the research was obtained from the Research Ethics Committee of Kuopio University Hospital. All participants were told that they were free to withdraw at any time and this would have no bearing on their treatment. Written informed consent was obtained from all participants for both the interview and research, as well as for information to be obtained from their treatment records. To guarantee confidentiality and anonymity, the interviews were coded and no citations that could reveal the identity of the informant were used. The names of the participants were changed. Due to the vulnerability of the group participants and the very sensitive, difficult issues discussed in the interviews, the participants were guaranteed that no person other than the main researcher would have access to the original interviews.
 
Results
To guarantee confidentiality and anonymity of the participants their names were changed. In text participants are called Aaro, Samuel, Juha, Leo, Tatu and Ilkka.
 
All the participants could remember the interviewer, who had acted as a group leader in the psychoeducation group. Aaro, Juha and Ilkka had the most specific memories about the group. Samuel and Tatu could summon up memories about the group in mainly general terms and could share their experiences of the group only after focusing the themes and questions in more specific terms. Leo was the only one who could not recall the intervention at all. Participants who remembered the group considered it to have been helpful in their situation.
 
The benefits of group psychoeducation for each patient were assessed by using the following overall categories derived from Antonovsky’s SOC theory with its three main components as categories (Table 2). “Comprehensibility” referred to cognitive aspects of experienced benefits and included themes such as gaining new information about schizophrenia and its treatment and restructuring one’s experiences as experienced benefits of the group. “Manageability” included themes involving different resources and skills gained and experienced as helpful in the group, and the emphasis was on behavioral aspects considered to be beneficial. Gaining new skills concerning coping with stress, managing with persistent symptoms, monitoring of early warning signs, seeking help and information, and peer support were included in this category. “Meaningfulness” included motivational and emotional aspects and themes, for example, answers involving hope, identification with appropriate role models, sharing, empowerment, reasonably challenging  activities and optimism. When a participant expressed benefits from more than one category, the primary and secondary benefits experienced were determined by making the category with more accounts the primary category.
 
Table 2. Experienced benefits of group psychoeducation in the study group.

 

Comprehensibility

Manageability

Meaningfulness

Aaro

++

-

+

Samuel

++

-

+

Juha

++

-

+

Leo

-

-

-

Tatu

+

-

-

Ilkka

++

+

+

 Note.  ++ = primary experienced benefit,  + = secondary experienced benefit,  - = no experienced   benefit


 Comprehensibility

 The results show that the benefits gained from the psychoeducation group came mainly in terms of new information and improved comprehensibility, although participants emphasized that they had forgotten a lot about the group during the four intervening years. The group seemed to work as a new, confidential forum where it became possible for the participants to obtain new information about the illness, ask questions, and get them answered. Aaro, Samuel and Juha mentioned that getting new information was the very best thing in the whole group experience. Respondents also emphasized their belief that this new information appeared to be reliable. The need for information was evident: Aaro, Juha and Tatu felt that before the group they had “some knowledge of schizophrenia”, but not enough. Samuel reported that before the group his level of knowledge was “zero”.

Human beings have an innate need to understand and have control over their lives. As Aaro stated in the interview “there should be an explanation, a reason for everything”. Psychotic illness and symptoms can often be very confusing and even frightening and people have a need to know what is happening to them. Aaro gave an example of fears that troubled him:

I have had fears that I would become disabled, break a limb or something, or maybe something unexpected happens … I would have to be in a hospital for the rest of my life or suffer some injuries, immobility … Or maybe I would lose my mind for good. These are the things I wonder about.

 It was hoped that the information offered would give the patients a chance to reinterpret and reorganize their experiences. It was evident in the interviews that participants were able to reflect on this new information in their personal situations and structure their experiences:

The information that was given about the symptoms, I think it was all true … I found out things about my own life … and thought about those things again and remembered things I had not remembered before … I was able to dredge up memories from my past. I think that without this group I would have never been able to talk about those things, here or elsewhere either. (Aaro)

Yes, yes. I found out that there can be almost same diseases, it was something really good to hear … you get a social phenomenon there that helps in healing…I was able to realize that earlier I didn’t understand my own thoughts, that was the feeling I got, what it really is to be in psychosis. … I think I realized that even before, but now I am sure ... I need help. (Juha)

 Manageability

One of the main aims of the intervention was to provide the participants with new strategies for coping with their illness and ways of handling stress better. In research interviews the participants were asked about the new coping skills and strategies they had learned. Only Ilkka could refer more specifically to the coping strategies he had learned in the group:

 For example, how do you know that you could get so seriously ill, and what the first symptoms and signs are … how you can prevent the worsening of symptoms and when you should go to the doctor or  notice that things are getting worse.

 The participants were also assigned homework between group sessions to help them practice new skills for coping. In the interviews, all the participants said that they had done at least part of the assignments but, on the other hand, none of them could recall the exact contents of these assignments:

 I guess I scrawled something on the papers, as far as I can recall. (Aaro)

 Meaningfulness

 One aim of the intervention was encourage sharing in the group, and in the light of the interviews this supportive environment was clearly realized. Group rules were created to support the structure of the group and help build an atmosphere of confidence and sharing for the participants. For example, Samuel emphasized that “keeping one’s mouth shut” was the most important rule in the group and admitted that without such a rule he would not have even participated in it. Other patients stressed the importance of confidentiality in the interviews as well:

 It was quite good that you get a chance to (speak)...confidentially, you don’t have to be afraid that you hear those things while walking down the corridors. (Aaro)

The participants believed that confidentiality worked well. For example, Aaro was able to share the very sensitive and personal difficult experiences of his illness. Samuel also shared his experiences about psychosis, alcohol abuse, and side-effects of his medication with the group, even though his medical records from that time postulated that he could not discuss his mental problems at all. The atmosphere of mutual understanding and confidentiality were probably of great importance in permitting him to dare to share his feelings and experiences.

Patients with schizophrenia often believe that their condition is very rare and uncommon. A normalizing rationale for explaining the emergence of symptoms in schizophrenia was therefore used in the group. Medical analogies were used to normalize mental illness and show schizophrenia to be a treatable illness. Patients found hope in the notion that they are not alone in their situation:

I found out that my illness is not that bad after all ... I can speak about it with other patients in my ward ... we won’t be here forever ... some day I’ll get out of the hospital...They had the same problems, almost, almost the same kinds … I felt that I am not alone after all, that others have the same things. (Aaro)

Sharing one’s experiences can be empowering and foster hope, but it can also be emotionally difficult for the patients:

I have had discussions about my mental illness so many times with doctors and psychologists ... they have asked whether I hear voices ... everything about ... how I felt and how I was doing when I stabbed that guy ... Sometimes it feels very bad ... now I can tell you that when the stabbing happened, I actually heard voices, I really was a sick man. Sometimes I just feel that I don’t want to talk about it all the time ... those are such bad memories, really bad. (Ilkka)

Despite this statement, Ilkka noted in the interview at the end of the group that he had a positive feeling about it. Also Aaro and Samuel said that sharing experiences was sometimes difficult and made them feel bad; on the other hand, an opportunity to share and listen to the experiences of others was viewed as interesting, and the information about the universality of schizophrenia and the experiences of others were considered to be a relief. A shared experience of illness or “shared fate” was evident also in following  quotation:

 We are all fellow sufferers here. All people have their own things, but we all have got to the hospital ... I think what we have in common is that everyone of us walks the same road, schizophrenia is the reason why we have to stay here. (Tatu)

 If patients are offered a sufficient level of challenge, it could imply their sense of meaningfulness (Bengtsson-Tops & Hansson, 2001). Therefore these challenges of learning new things were offered in the group, but always kept in mind the participants’ personal abilities and limitations. For people, who appreciate and can easily adopt the school-like structure, the group format with its lessons and written material can be very important. Juha, who had graduated from upper secondary school before he became ill, stated:

 The written material was the number one thing, for me at least.

 The meaningfulness of the group experience can also be understood as an active attempt to take part in one’s own treatment: For example, Leo, who did not even recall attending the psychoeducational group, brought out in the interview that he has serious memory problems; despite this, he said he wants to take part in all kinds of therapeutic activities in the ward because he wants to “rehabilitate the brain”. He explained:

 But my brain just doesn’t work … it is ramshackle … it doesn’t work at all … this situation comes near to brain damage … and probably is  brain damage ... I take part in different interventions just because of interest, and of course I hope that maybe they could help me in some way … interest is the main reason (to participate).

Although Leo could not recall the group, he emphasized that groups are in general important and meaningful to him in terms of active participation in his own treatment and help him maintain hope in his difficult situation.

Discussion
The present study sought to examine the experienced benefits of group psychoeducation four years after the intervention from a participant perspective. The findings suggested that participants had fairly positive experiences, especially in regard to comprehensibility, and were able to take in information about the illness and adapt it to their own situation. The study supported the findings of previous research that psychoeducation has beneficial effects and  also long-term psychiatric patients need and want information about their illness, consider that information to be helpful in their situation and give them hope even if they have suffered from schizophrenia for several years (Bäuml et al., 2006; Chien et al., 2001; Griffiths, 2006; Wiersma et al. 1998).  Participants were able to reflect on this new information in their personal situations and structure their experiences in such a way that the information became the participant's personal knowledge, in the same way as Kilkku et al. (2003) found in their study. Participants, however, emphasized that they had forgotten a lot about the group during the four intervening years, which is consistent with some previous findings that patients can internalize information, but booster sessions are probably needed to consolidate learning (Macpherson, Jerrom, & Hughes, 1996; Zygmunt et al., 2002).
 
Most participants in this study also experienced benefits related to meaningfulness and perceived the group as beneficial since it gave them a new sense of hope for the future. The benefits from psychoeducation included a sense of “shared fate” and a chance to note that they are not alone in their problems; all of these issues are related to the individual’s sense of coherence. The opportunity to share and listen to the experiences of others was viewed as interesting, and the information about the universality of schizophrenia, i.e. the notion that they are not alone in their situation, and shared discussions were experienced as important and mitigating. These findings concur with what Kilkku et al. (2003) found studying the meaning of information-giving to patients with first-episode psychosis. Sharing difficult experiences can reduce the feeling of isolation and enhance the sense of belonging, but it can also be emotionally difficult for patients. This issue was illustrated in present study as the group was seen as difficult but helpful.
 
As Spaniol et al. (2002, 2008) have noted, gaining control over the illness requires having effective coping skills and strategies for dealing with symptoms and stressors. Although one of the main aims of the intervention was also to provide the patients with new strategies for stress management, coping with their illness and ways of handling stress better, this aim was not sufficiently fulfilled. Still, all the participants who remembered attending the group expressed satisfaction with the group experience and considered group psychoeducation to have been helpful in their situation. It has been proved that forensic schizophrenia patients can also develop skills and roles when provided with meaningful rehabilitation (Schindler, 2005). Compared to those studies where the effectiveness in terms of skills has been proved, the group program presented here was of short duration. Clearly longer and more intensive interventions are needed to help these patients adopt new active coping strategies for managing their symptoms and illness.
 
It has been recommended that we also give patients whose illness affects their cognitive functioning an opportunity to participate in psychosocial interventions (Bengtsson-Tops & Hansson, 2001; Välimäki et al., 1996). In this study, participants’ cognitive deficits and disturbances were taken into account when planning the intervention, and visual aids and other techniques were used. Leo, who suffered from substantial cognitive problems and thought disorder, could still not even recall he had attended the group four years earlier. Massive formal thought disorder has been, in fact, been defined in recent research as one of the few mandatory contraindications to psychoeducation (Bäuml et al., 2006), but the aim of the present study was to also give those patients, who prior to this group very seldom had a chance to participate in any psychosocial group interventions, an opportunity, as it has been postulated that interventions with unconditional support and zero exclusion as principles can provide hope to patients with persistent illness and support individuals’ recoveries (Bäuml et al., 2006; Mueser et al. 2002).
 
Findings in the present study are largely similar to those of Bäuml and his colleagues (2006), who have found that the specific effective factors of psychoeducation seem to be the illness-related key information and emotional topics, and those obtained from Sibitz et al. (2007), who found that participants especially emphasized the information received, reflecting the new information about illness and life, exchanging information with other patients, and learning that they are not alone in their situation, as positive experiences in group psychoeducation.
 
Participants expressed very few benefits connected to manageability or the behavioral level of the outcomes. These results are also in line with previous research. It has previously been recognized that even though behavioral changes are not achieved, psychoeducation can still enhance the participants’ quality of life by offering information and a chance to share experiences, and that it creates a useful foundation in the treatment of schizophrenia. Other and more comprehensive long-term treatment efforts and methods need to be applied in addition to brief pychoeducational groups, especially in the treatment of patients with persistent illness (see, e.g., Bäuml et al., 2006; Kilian et al., 2001; Mueser et al., 2002) but psychoeducational programs can serve as a basic therapeutic component even though more individualized treatment are needed to target the specific problems of forensic patients (Hodgins, 2002)
 
Because of the nature of the participants’ illness and the criminal offenses they had committed, durations of inpatient treatment are often very long and most of the participants in the present study were still hospitalized four years after the intervention. It is therefore impossible to estimate whether the intervention shortened the duration of treatment among these participants. Participants still found the intervention helpful and expressed benefits from it even four years after attending the group.
 
There are limitations concerning the present study. As indicated above, due to ethical reasons the inter-rater reliability of the analysis was not possible to assess, and the issues of credibility and transferability were taken into account by using quotations from the original interview material in the text. The sample in this study, due to the study’s pilot nature, was also very small, which may reduce the transferability of the present findings to other contexts.

Conclusions
Comprehensibility, manageability and meaningfulness proved to be useful concepts for understanding the experienced benefits, related both to the active treatment factors and more non-specific effective treatment factors that psychoeducation produces for the participants. The findings of the present study support the idea that long-term psychiatric inpatients gained new information about their illness from the psychoeducation group and considered the information obtained to be helpful in their situation and gave them hope, even though they had suffered from schizophrenia for several years. Our results indicated that for some participants the group acted as a forum where a new understanding of their situation was gained. It would be advantageous that as many patients as possible be given a chance to participate in psychoeducation groups, because psychoeducation groups with a recovery orientation may provide their participants a new sense of hope and empowerment, and for some people even a unique context to discuss the very sensitive issues that would be difficult to discuss in other circumstances. Further research with a larger sample will be conducted based on results obtained from the present study.


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