Pilot Study of the Effectiveness of the Family-to-Family Education Program

A total of 37 consenting family members were drawn from five Family-to-Family Education Program classes that were scheduled to begin in the fall of 1998 in the greater Baltimore metropolitan area. All the classes were conducted by teachers who were trained by the program's originator and director in accordance with the program manual. Thirty-one (84 percent) of the participants were women; 30 (81 percent) were Caucasian, and seven (19 percent) were African American; and 21 (57 percent) were parents. The participants' mean±SD age was 55±11.72 years, and they had a mean±SD of 14.9± 1.85 years of education. Overall, the family members were caring for 37 persons who had a mental illness. The mean age of those receiving care was 33±14.92 years, and their mean number of previous hospitalizations was 3.2±1.11. Twenty-one (57 percent) were men.

Study participants were assessed prospectively at baseline, immediately after completion of the program, and six months after program completion. The participants' subjective burden—for example, worry, displeasure, and subjective global displeasure—and objective burden—for example, assistance with daily living and supervision—of mental illness as well as their attitudes toward professionals were measured by use of subscales of the Family Experience Interview Schedule (8). Indexes of self-esteem, sense of mastery, social network, depression, and physical health were derived from the Family Impact Study (9). Empowerment was measured with the Family Empowerment Scale (10). The tests were administered by trained family member interviewers during 35- to 45-minute telephone calls to the participants. The calls were monitored for reliability.

We conducted paired t tests (one-tailed) to compare baseline assessments with completion assessments. To determine whether gains observed at completion were sustained after six months, we conducted paired t tests (two-tailed) between assessments at completion and at six-month follow-up. We applied a Bonferroni correction to minimize the possibility of type I error and required a p value of .004 or less.

Assessments at program completion indicated that the participants felt significantly more empowerment in the community, in their family, and with the service system than they did at baseline; they also experienced less displeasure and worry about their ill family member (Table 1). No differences were noted in measures of objective family burden, attitudes toward professionals, self-esteem, sense of mastery, depression, social network, and physical health. No significant improvements or deteriorations were noted for any measure between program completion and the six-month follow-up.

The results of this study suggest that the Family-to-Family Education Program enhanced family members' empowerment and reduced their subjective burden of mental illness by diminishing worry and displeasure. These benefits were evident by the end of the 12-week program, and they were sustained for six months after program completion. Given that the program is widely used and has received considerable financial support from state governments (5), this initial test of efficacy is important.

Completing the program did not appear to affect the participants' objective burden of mental illness, that is, the actual, tangible "work" that they do to care for their ill family member, nor did it affect their self-esteem or sense of mastery. The intervention may have been too brief to have had an impact on these domains, or perhaps our measures were not sensitive enough to detect any changes.

Although this study focused on the impact of the Family-to-Family Education Program on family member participants, the results could have implications for improving patient outcomes. Reduced worry and displeasure might allow program participants to provide a less tense and stimulating family environment for the patient. Improvements in family members' empowerment could enhance their ability to advocate for better care, which in turn could result in more appropriate treatment for patients. However, the program's implications for patients have not been empirically evaluated.

It should be noted that the study was limited by its small size and scope and the lack of a control group. Nonetheless, the results are encouraging with respect to the efficacy of the program.

Dr. Dixon is associate professor of psychiatry at the University of Maryland School of Medicine in Baltimore and associate director of research at the Department of Veterans Affairs Capital Health Care Network Mental Illness Research, Education, and Clinical Center in Baltimore. Ms. Stewart, Ms. Delahanty, Dr. Lucksted,and Ms. Hoffman are affiliated with the Center for Mental Health Services Research at the University of Maryland. Dr. Burland is deputy executive director of the education and training department at the National Association for the Mentally Ill in Arlington, Virginia. Address correspondence to Dr. Dixon, University of Maryland, Department of Psychiatry, 701 West Pratt Street, Room 476, Baltimore, Maryland 21201 (e-mail, [email protected]).