What Do Relatives of People With Schizophrenia Find Helpful About Family Intervention?

Transcription

1 What Do Relatives of People With Schizophrenia Find Helpful About Family Intervention? by Richard J. Budd and Ian C.T. Hughes Abstract While research indicates that family intervention is of benefit to schizophrenia patients and their relatives, it remains unclear why it is beneficial. Methodologies developed in psychotherapy process research may be of use in answering this question. The present study examines the applicability of one such methodology to a clinically based family intervention program. Relatives' (n = 20) reports of what they found helpful and unhelpful about the program were examined and the perceived therapeutic impacts of the program are reported. The implications of these results for future research are discussed. Schizophrenia Bulletin, 23{2):341-34,199. Family intervention has developed as a result of a confluence of theory and need. The theoretical rationale for family intervention comes from studies showing that schizophrenia patients who live in families that have high levels of expressed emotion (EE) have relapse rates two to three times higher than those who live in low EE families (see Bebbington and Kuipers 1994 for a review). As a result of this research, behavioral interventions have been developed to reduce EE, and hence relapse rates, by facilitating problem solving and communication within the family (e.g., Goldstein et al. 19; Falloon et al. 192). In addition, demand for family intervention has developed as a result of changes in the organization of mental health services, which over the past 20 years have allowed people with schizophrenia to spend much less time in the hospital and much more time at home (Weidermann et al. 1994). Against this background there has been a growing recognition of the considerable degree of burden on some relatives (e.g., MacCarthy et al. 199), prompting the development of mental health services that meet the needs of both patients and their relatives (Smith and Birchwood 1990). Considerable evidence shows that family intervention can reduce relapse rates at 1 and 2 years' followup (see Lam 1991 for a review), and recent evidence suggests that reduced but clinically significant gains can be maintained even at years' followup (Tarrier et al. 1994). It is, however, difficult to draw conclusions from this research literature that can usefully guide clinical practice, which in part reflects the nature of the controlled outcome studies that have been conducted to date. As Lam (1991) notes, the focus of these studies has been to address the question of whether family intervention is effective in reducing relapse rates, rather than addressing why these interventions are effective. Thus, most outcome studies have used treatment programs with a diverse range of interventions that cannot be easily contrasted with each other. The research literature thus provides few clear guidelines to shape effective clinical practice. To address this question, Lam (1991) has argued that future outcome studies should employ dismantling research designs to identify which aspects of the interventions are effective. An alternative methodology that may be capable of addressing the question of why family intervention is effective can be found in the psychotherapy research literature. A series of meta-analyses demonstrated that after 20 years of psychotherapy outcome research, the literature provided little clear evidence of the superiority of one intervention over another (see Stiles et al. 196 for a review). As a result, the focus of research shifted to emphasize therapeutic process in addition to outcome (Greenburg 196; Stiles et al. 196). The aim of this research has been to identify the therapeutic processes that account for successful outcomes (e.g., Hawton et al. 192; Murphy et al. 194; Lange and van Woudenberg 1994), and the results of this process research may be particularly applicable to clinical practice (Parry et al. 196). Reprint requests should be sent to Dr. RJ. Budd, Deptf. of Clinical Psychology, Whitchurch Hospital, Whitchurch, Cardiff CF4 XB, United Kingdom. 341

2 Schizophrenia Bulletin, Vol. 23, No. 2, 199 R.J. Budd and I.C.T. Hughes One tentative conclusion from this research is that the apparent equivalence of ostensibly different psychological interventions may be due to their sharing common therapeutic components (Stiles et al. 196). Thus, the emphasis in psychotherapy research has shifted from simply contrasting different interventions to including a focus on the processes that underlie them. One methodology developed to address therapeutic process is to examine clients' reports of what they find helpful and unhelpful about different therapeutic interventions (Stiles and Snow 194; Elliott 195; Llewellyn et al. 19). This methodology has aided our understanding of both cognitive-behavioral and psychodynamic/interpersonal therapies and has led to the development of models that integrate these different therapeutic interventions into one consistent treatment approach (e.g., Shapiro et al. 1992). Given the contribution of this approach to our understanding of the processes of successful psychotherapy, the present study explores whether this methodology may also be applicable to family intervention, shedding light on some of its underlying therapeutic processes. Methods Subjects. The respondents were the primary relatives of 20 people with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder (American Psychiatric Association 19). The mean age of the respondents was 50 years (range 2-65). Fifteen respondents were parents of the patient (12 mothers, 3 fathers), 3 were wives, 1 was a husband, and 1 a sister. Patient mean age was 29 years (range 1-54). The mean length of illness was 5 years (range 1-2). Intervention. The intervention was provided as part of a routine clinical service offered to families in South Wales, United Kingdom. The family intervention program, which has been described in detail elsewhere (Hughes et al. 1996), was provided by a specialist therapeutic team that has been providing this service for over 10 years. Therapists are drawn from a variety of professions, including clinical psychology, psychiatry, occupational therapy, and social work. Two therapists visit each patient and family at home on a regular basis. After completion of an educational package (Birchwood and Smith 1991), the therapists jointly complete an assessment of the family's needs and identify specific behavioral goals to be the focus of the family intervention. This intervention focuses on improving the family's problem-solving and communication skills through the therapists' modeling of appropriate behavior and setting of behavioral goals for the family members. The therapists encourage family members to become actively involved in local services and to set goals to promote the patient's active rehabilitation. Work toward these goals may include encouraging patients to increase the range of daily activities and household chores they undertake, encouraging them to engage in activities independent of the family, and focusing on specific problems such as the use of public transportation, self-care, and getting up in the morning. Data Collection and Coding. Following the completion of the family intervention program, respondents were contacted by a research assistant, who introduced herself as being independent from the clinical team, to arrange time to interview the principal relative privately in the home. The semistructured interview was designed to provide sufficient opportunity for relatives to recall everything they had found helpful and unhelpful about the family intervention program. To facilitate this recall, the research assistant provided open-ended prompts (e.g., "Can you tell me more about that?") following the initial response to each structured question. The interview schedule was split into three sections. (A copy of the interview schedule is available from the first author on request.) The first section involved a review of relatives' memories and experiences of their relative's first hospital admission. (This section was intended as an introduction to prompt relatives to begin speaking freely.) The second section focused on what the relatives had found helpful and unhelpful about the educational intervention; data are reported elsewhere (Budd and Hughes, in press). The third section of the interview focused on what the caregivers reported to be helpful and unhelpful about the family intervention program. These data are reported below. The relatives' responses were recorded, and each helpful or unhelpful aspect of the family intervention was transcribed onto a separate card. The transcriptions were edited, removing repetitions, speech errors, and redundancies to facilitate subsequent coding. Categories for coding the data were then derived from an initial analysis of all the participants' responses. Each coder was provided with a list of written definitions for each category. (Examples of items that were coded into each category are presented in the appendix.) Data Analysis. Two methods of data analysis were used. First, each statement was independently coded by three judges (experienced members of the family intervention team) into the predefined categories in order to examine the adequacy of the coding system. Three criteria need to be met to demonstrate that the categories adequately represent the data. First, each category should contain sufficient items to indicate that it does not repre- 342

3 Relatives of People With Schizophrenia Schizophrenia Bulletin, Vol. 23, No. 2, 199 sent a rare or idiosyncratic response. Second, few items should be coded in the "other," nonspecified category, thus demonstrating that the coding system accounts for most of the data. Third, there should be a high level of interrater reliability, demonstrating that the categories have been reliably defined. Once the adequacy of the coding system had been established, the data were reanalyzed using a rating, rather than the categorical, coding system. The data were reanalyzed in this way for the following reasons. First, as Llewellyn et al. (19) note, individual statements can imply the presence of more than one therapeutic impact. Thus, while a categorical coding system is unable to represent such data, a rating system enables each statement to be coded as indicating the presence or absence of each impact. Moreover, as these authors note, respondents' comments on what they found helpful and unhelpful in therapy can imply a particular therapeutic impact without this impact being unambiguously stated. To account for this, five coders (experienced members of the family intervention team) rated the presence or absence of each therapeutic impact (category) on a 4-point scale (definitely not present, possibly present, probably present, definitely present). This scale was scored 0, 0.33, 0.66, and 1, respectively, so that mean scores for each impact represent the frequency with which that impact is cited (i.e., a mean score of 0.5 indicates that the impact was cited by 50% of respondents). Relatives were chosen as the unit of data analysis, with coders providing a global rating of the presence or absence of each impact for each relative on the basis of all the statements provided by that relative. Following Llewellyn et al. (19), the alpha coefficient (Cronbach 1951) was calculated to estimate the interrater reliability of these ratings. Results The total number of comments classified into each of the listed categories (impacts) and the number of relatives who cited each impact are presented in table 1. Comments were classified only if at least two of the three judges agreed to that item's coding. In this way, 6.6 percent of the items were coded, with the judges failing to reach agreement on the categorization of the remaining items. The kappa coefficient (Fleiss et al. 199) was calculated for the whole data set (including data on which the judges disagreed) to estimate the degree of interrater reliability. A high level of reliability was found among the three coders (K = 0.3; p < 0.001). Furthermore, table 1 indicates that the categories appear to represent the data adequately, with only a small number of items being classified into the two miscellaneous categories. Of the eight items in the miscellaneous positive category, four concerned unspecified helpful advice the therapists had offered (e.g., "they [the therapists] offered advice and answered our questions"), making it impossible to classify these items into the more specific categories listed in table 1. The remaining four items in the miscellaneous positive category all concerned idiosyncratic responses. Of the 13 items classified into the miscellaneous negative (unhelpful) category, 3 implied the intervention had presented a pessimistic and negative view of schizophrenia. The remaining items included negative reactions to the therapists (e.g., "We did not feel supported by the therapists") and to specific aspects of the intervention (e.g., "Suggestions for activities over-stressed him [the patient]"). Table 1 also presents the alpha coefficient and the average rating across relatives for each impact, with the impacts ranked by the frequency with which they were cited by the relatives. The alpha coefficients are all above 0., indicating a high degree of interrater reliability. The most commonly cited impact was that the intervention had increased the relatives' knowledge about, and understanding of, the illness, with just over 0 percent of the sample reporting this impact. The next four most frequently cited impacts all relate to issues of social and emotional support. Specifically, the second most frequently cited impact was that relatives felt supported by the intervention, which helped them feel they were not alone in facing the challenges presented by the illness. The third most frequently cited impact was that the relatives had found it helpful to know they could contact the family intervention therapists for help and advice should any particular difficulties or problems arise. (Surprisingly, the relatives rarely initiated contact with the family intervention team members, despite this perception.) The next two most frequently cited impacts were, respectively, that the relatives had felt reassured and encouraged by the intervention and had found the therapeutic alliance helpful. With regard to the former impact, they noted that they had felt reassured to know that they were doing the right things to manage their relative's difficulties and had been encouraged to continue their efforts in this regard. Reports of the helpful nature of the therapeutic alliance focused on the perceived empathy and warmth of the therapists and the genuine concern the therapists had expressed. The last six therapeutic impacts listed in table 1 relate to specific features of the family intervention program. First, just over 50 percent of the sample indicated that the program had helped increase their relative's level of activity. This specific feature of the present family intervention program encourages patients to increase their activities around the house and make active use of local resources, 343

4 Schizophrenia Bulletin, Vol. 23, No. 2, 199 R.J. Budd and I.C.T. Hughes Table 1. Impacts of family intervention Impact description Increased knowledge/understanding of schizophrenia Relatives felt supported Useful to have a contact point in case of emergencies Relatives felt reassured/encouraged Relatives found the therapeutic alliance helpful Patient encouraged to increase activity levels Advice on managing symptoms Increased caregivers' tolerance of problem behavior Improved communication between family members Increased relatives' acceptance of illness Increased understanding about medication Miscellaneous positive Miscellaneous negative Number of comments Number of relatives Alpha Mean including day centers, voluntary support groups, local college courses, and other social activities. Similarly, just over 50 percent of the sample indicated that they had found it useful to be given advice on managing symptoms. In addition to specific advice on managing hallucinations and delusions, this support also included advice on monitoring early signs and on relapse prevention. Fifty percent of the sample noted that the intervention had helped them to become more understanding and tolerant of their relative's difficulties and to reattribute some of their relative's problem behavior to the illness. In a similar vein, the next most frequently cited impact was that the intervention had helped improve communication within the family, with just under 50 percent of the sample citing this impact. In this regard, relatives specifically noted that the intervention had not only helped them discuss the illness more freely, but had also helped them learn how to discuss a broad range of other issues without arguing. Finally, just over 40 percent of the relatives indicated that the intervention had helped them come to terms with, and accept, the illness, with 35 percent of the sample also indicating that the intervention had helped increase their understanding about medication. Discussion The results suggest that, for the current sample at least, the relatively nonspecific positive impacts of emotional support, backup, and reassurance were more commonly reported as helpful by relatives than were the more specific impacts concerning behavior change and skills acquisition. Even though the family intervention program contained a large and explicit skills-training component, the relatives in the present sample reported finding emotional support and reassurance to be at least as helpful as, if not more helpful than, the more specific therapeutic factors. Similar findings have emerged from patient evaluations of the therapeutic impacts of cognitive-behavioral group therapy for anxiety disorders (Powell 19) and obsessive-compulsive disorder (Enright 1991) and of individual cognitive-behavior therapy sessions (Llewellyn et al. 19). However, when interpreting the significance of this result, it is important to bare in mind the following caveats. This result may, at least in part, reflect either a lack of sensitivity in the current design or specific characteristics of the present sample. It is therefore important to replicate this result on different samples to examine whether the relative perceived importance of different aspects of family intervention varies between samples. The apparent outcome equivalence of ostensibly different psychological therapies (Smith et al. 190; Shapiro and Shapiro 192; Robinson et al. 1990) suggests that there may be common ingredients in these therapies that account for their successful outcomes (Stiles et al. 196). These common ingredients usually include therapistclient relationship factors such as alliance, personal qualities of the therapist such as warmth and empathy, and therapy elements such as remoralization, universalization, goal-setting, and informing/understanding (Russell 1994). Many of the impacts listed in table 1 bear a close resemblance to these common ingredients of therapy. For example, the most frequently cited positive impact was an increase in relatives' knowledge or understanding of schizophrenia. Furthermore, the relatives reported feeling supported by the family intervention therapists, with 5 percent of the sample noting that they had found the therapeutic alliance helpful, and 60 percent of the sample reporting that they been reassured and encouraged by the intervention. 344

5 Relatives of People With Schizophrenia Schizophrenia Bulletin, Vol. 23, No. 2, 199 Despite the apparent importance of these common therapeutic elements, the relatives nonetheless cited a number of impacts that are specific to family intervention programs. Most notably, they reported that the intervention had helped them become more tolerant of their relative's behavior by helping them reattribute some problem behaviors to the illness. In addition, they noted that the intervention had improved communication between family members, in relation to both the illness and other issues. Given that the rationale for family intervention developed from attempts to reduce high EE through improved communication and problem solving within the family, it is encouraging that relatives found this aspect of the intervention helpful. It is similarly encouraging that more than 50 percent of the sample reported finding both information on managing symptoms and the rehabilitative component of the program helpful. Schooler et al. (1995) noted that, just as in the psychotherapy outcome literature, family intervention outcome studies have not demonstrated any significant differences in outcome between different family intervention programs, which may suggest that common therapeutic ingredients account for the efficacy of family intervention programs but involve ostensibly different therapeutic interventions. If such common therapeutic processes do exist, however, calling them "nonspecific factors" may be misleading. For example, the quality of the therapeutic alliance and the perceived empathy of the therapists may be dependent on the therapists demonstrating an accurate understanding of schizophrenia and its problems and accurately acknowledging and attending to family members' needs. In this way, nonspecific therapeutic impacts may result from specific interventions with a clear structure and goal. Clearly, these observations are highly speculative, but the present results do, nonetheless, indicate that methodologies developed in the psychotherapy process research may be profitably applied to family intervention. Clients' reports that particular aspects of therapy are helpful do not necessarily imply that these specific mechanisms account for therapeutic change. Such reports do, however, contribute to our understanding of family intervention. The examination of clients' reports of what they found helpful about therapy has significantly contributed to our understanding of the processes that account for successful psychotherapy (Shapiro et al. 1992), and the present results suggest that this methodology may also be capable of furthering our understanding of family intervention. Future studies should explore a number of issues. First, such studies should examine the reported helpful and unhelpful impacts of family intervention on a session by session basis, relating clients' reports of therapeutic impacts to therapists' reports of the focus and aims of each session. This methodology is likely to be more powerful than the present one in isolating the specific impacts of family intervention, and may help us chart the changing process of therapy across sessions. Second, it would be useful to examine the relationship between the reported therapeutic impacts of family intervention and measures of the family emotional climate, such as EE (Leff and Vaughn 195), family coping style (Birchwood and Cochrane 1990), and patient rejection (Kreisman et al. 199; Lebell et al. 1993). In particular, it would not be surprising if certain aspects of family intervention were more relevant and helpful in some family environments than others. (For example, families that are high in criticism and hostility may find communication training more helpful than low EE families do.) Third, studies should relate therapeutic impacts to measures of outcome to further elucidate the therapeutic mechanisms that may underlie family intervention. Finally, it would be interesting to consider patients', as well as relatives', reports of what they find useful about family intervention, although they may have difficulty articulating such views. References American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: The Association, 19. Bebbington, P., and Kuipers, L. The predictive utility of expressed emotion in schizophrenia: An aggregate analysis. Psychological Medicine, 24:0-1, Birchwood, M., and Cochrane, R. Families coping with schizophrenia: Coping styles, their origins and correlates. Psychological Medicine, 20:5-65, Birchwood, M., and Smith, J. Understanding Schizophrenia. Birmingham, England: Bromsgrove & Redditch Health Authority, Budd, R.J., and Hughes, I.C.T. What do the carers of people with schizophrenia find helpful and unhelpful about psycho-education? Clinical Psychology and Psychotherapy, in press. Cronbach, L.S. Coefficient alpha and the internal structure of tests. Psychometrika, 16:29-334, Elliott, R. Helpful and nonhelpful events in brief counseling interviews: An empirical taxonomy. Journal of Counseling Psychology, 32:30-322, 195. Enright, S. Group treatment for OCD: An evaluation. Behavioural Psychotherapy, 19:12-192, Falloon, I.R.H.; Boyd, J.L.; McGill, C.W.; Ranzani, J.; Moss, H.B.; and Gilderman, A.M. Family management in 345

6 Schizophrenia Bulletin, Vol. 23, No. 2, 199 R.J. Budd and I.C.T. Hughes the prevention of exacerbation of schizophrenia: A controlled study. New England Journal of Medicine, 306: , 192. Fleiss, J.L.; Nee, J.C.M.; and Landis, J.R. Large sample variance of kappa in the case of different sets of rates. Psychological Bulletin, 6:94-9, 199. Goldstein, M.J.; Rodnick, E.H.; Evans, J.R.; May, P.R.A.; and Steinberg, M.R. Drug and family therapy in the aftercare of acute schizophrenics. Archives of General Psychiatry, 35: , 19. Greenburg, L.S. Change process research. Journal of Consulting and Clinical Psychology, 54:4-9, 196. Hawton, K.; Reibstein, J.; Fieldsend, R.; and Whally, M. Content analysis of brief psychotherapy sessions. British Journal of Medical Psychology, 55:16-16, 192. Hughes, I.C.T.; Abbati-Yeoman, J.; Hailwood, R.; and Budd, R.J. Developing a family intervention service for serious mental illness: Clinical observations and experiences. Journal of Mental Health, 5(2): , 19%. Kreisman, D.E.; Simmens, S.J.; and Joy, V.D. Rejecting the patient: Preliminary validation of a self-report scale. Schizophrenia Bulletin, 5(2): , 199. Lam, D.H. Psychosocial family intervention in schizophrenia: A review of empirical studies. Psychological Medicine, 21: , Lange, A., and van Woudenberg, M. Cognitive restructuring in behaviour therapy and in psychoanalytic therapy: A content analysis. Behavioural and Cognitive Psychotherapy, 22:65-3, Lebell, M.B.; Marder, S.R.; Mintz, J.; Minty, L.I.; Tompson, M.; Wirshing, W.; Johnston-Crank, K.; and McKenzie, J. Patients' perceptions of family emotional climate and outcome in schizophrenia. British Journal of Psychiatry, 162:51-54, Leff, J.P., and Vaughn, C. Expressed Emotion in Families. New York, NY: Guilford Press, 195. Llewellyn, S.P.; Elliott, R.; Shapiro, D.A.; Hardy, G.; and Firth-Cozens, J. Client perceptions of significant events in prescriptive and exploratory periods of individual therapy. British Journal of Clinical Psychology, 2: , 19. MacCarthy, B.; Lesage, A.; Brewin, C.R.; Brugha, T.S.; Mangen, S.; and Wing, J.K. Needs for care among the relatives of long-term users of day care: A report from the Camberwell high contact survey. Psychological Medicine, 19:25-36, 199. Murphy, P.M.; Cramer, D.; and Lillie, F.J. The relationship between curative factors perceived by patients in their psychotherapy and treatment outcome: An exploratory study. British Journal of Medical Psychology, 5:1-192, 194. Parry, G.; Shapiro, D.A.; and Firth, J. The case of the anxious executive: A study from the research clinic. British Journal of Medical Psychology, 59: , 196. Powell, T.J. Anxiety management groups in clinical practice: A preliminary report. Behavioural Psychotherapy, 15:11-1, 19. Robinson, L.A.; Berman, J.S.; and Neimeyer, R.A. Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 10:30-49, Russell, R. Report on Effective Psychotherapy: Legislative Testimony. New York, NY: Hillgarth Press, Schooler, N.R.; Keith, S.J.; Severe, J.B.; and Matthews, S.M. Maintenance treatment of schizophrenia: A review of dose reduction and family treatment strategies. Psychiatric Quarterly, 60:29-292, Shapiro, D.A.; Barkham, M.; Reynolds, S.; Hardy, G.; and Stiles, W.B. Prescriptive and exploratory psychotherapy: Toward an integration based on the assimilation model. Journal of Psychotherapy Integration, 2:253-22, Shapiro, D.A., and Shapiro, D. Meta-analysis of comparative therapy outcome studies: A replication and refinement. Psychological Bulletin, 92:51-604, 192. Smith, J.V., and Birchwood, M.J. Relatives and patients as partners in the management of schizophrenia: The development of a service model. British Journal of Psychiatry, 156: , Smith, M.L.; Glass, G.V.; and Miller, T. The Benefits of Psychotherapy. Baltimore, MD: Johns Hopkins University Press, 190. Stiles, W.B.; Shapiro, D.A.; and Elliott, R. Are all therapies equivalent? American Psychologist, 41:165-10, 196. Stiles, W.B., and Snow, J.S. Dimensions of psychotherapy session impact across sessions and across clients. British Journal of Clinical Psychology, 23:59-63, 194. Tarrier, N.; Barrowclough, C; Porceddu, K.; and Fitzpatrick, E. The Salford intervention project for schizophrenic relapse prevention: Five- and eight-year accumulating relapses. British Journal of Psychiatry, 165:29-32, Weidermann, G.; Hahlweg, K.; Hank, G.; Feinstein, E.; MUller, U.; and Dose, M. Deliverability of psychoeducational family management. Schizophrenia Bulletin, 20(3):54-556,

7 Relatives of People With Schizophrenia Schizophrenia Bulletin, Vol. 23, No. 2, 199 Acknowledgments The authors acknowledge the helpful comments provided by the anonymous reviewers on an earlier version of this manuscript. We are grateful for the help of Maria Grazia Cocchiara with data collection and of Othniel Smith with data analysis. The Authors Richard J. Budd, Ph.D., M.Sc, B.Sc, and Ian C.T. Hughes, M.A., M.Sc, are Clinical Psychologists, Department of Clinical Psychology, Whitchurch Hospital, Cardiff, United Kingdom. Appendix, Examples of Relatives' Responses That Were Coded Into Each of the Following Categories Increased knowledge/understanding of schizophrenia: The Schizophrenia Therapeutic Educational Project (S.T.E.P.) therapists explained what the illness was. They [the therapists] explained the illness and symptoms. They helped me understand the "voices" are part of his [the patient's] illness. Relatives felt supported: We [the relatives] felt supported and helped. It helped to know we weren't alone. I appreciated the support. The support was comforting. Useful to have a contact point in case of emergencies: It helps to know I [the relative] can contact the S.T.E.P. team if I need to. It's nice to know the S.T.E.P. team are there if I [the relative] need them. Relatives felt reassured/encouraged: The meetings reassured me I was doing a good job [of caring]. They [the therapists] provided reassurance and stopped me worrying. Relatives found the therapeutic alliance helpful: The S.T.E.P. therapists made us feel at ease. They [the therapists] were very accommodating and friendly. They were very understanding. Patient encouraged to increase activity levels: They discussed things he [the patient] could do to help around the house. They encouraged him [the patient] to attend daytime activities. They encouraged him to attend Tegfan [the day hospital]. Advice on managing symptoms: They [the therapists] explained the early signs of relapse. It helped to realize that arguing about the "voices" was pointless. We discussed ways of distracting him from the "voices." Increased relatives'tolerance of problem behavior: The visits helped us be more patient with him [the patient]. The S.T.E.P. visitors explained that [the patient] was not lazy, but sleeping a lot is a common symptom. Improved communication between family members: The meetings helped us [relative and patient] talk about the illness. I'm now more able to discuss things with him [the patient] without upsetting him. Increased relatives' acceptance of illness: Talking about it helped us feel more at ease with the illness. It helped my wife accept the illness. It helped me [the relative] feel less embarrassed about the illness. Increased understanding about medication: The S.T.E.P. visitors provided useful information about medication. They explained the medication helps prevent relapses. [The patient] found it helpful to talk about the pros and cons of the medication. 34