4. Discussion
anxiety, psychosis, ’ psychosis, depression, schizophrenia, chronic caregiving stress, hostility
SECONDARY
Studies have demonstrated the effective use of mindfulness training in reducing caregiver stress. Our research team conducted a randomized controlled trial involving Chinese caregivers, based on an 8-week benchmark mindfulness-based program and caregivers of people with mixed medical conditions [We did not find evidence to support Hypothesis 1. No significant differences were found in all caregivers’ outcomes between the MBFPE and FPE groups. When we focused on within-group changes, there were still no significant results found in either of the arms. We noticed that the caregivers reported improvements with small to large effect sizes in effects on family, positive caring experience, physical distress, depression, and anxiety after MBFPE. Only the improvement in effect on family reached the level of statistical significance. The caregivers who received conventional FPE reported improvements with small effect sizes in the caregiving burden, effect on family, physical distress, well-being, and non-attachment, but none of them reached the level of statistical significance. The time × group interaction effects of the MBFPE and FPE groups did not show significant changes in any of the caregivers’ outcomes. We did not replicate the findings of a recent systematic review [There may be three reasons for the absence of superior effects of the mindfulness-based psychoeducation program in our study. First, our restrictive inclusion criteria meant that the caregivers in our study had experienced a family transition, as the onset of their family members’ psychosis was within the last 3 years. Compared with caregivers who experienced chronic caregiving stress, the caregivers in our study may have felt overwhelmed by the drastic changes in the mental condition of their family members after the onset of psychosis and the subsequent adjustments made by the entire family. For individuals who experience major losses or life changes, learning and practicing mindfulness exercises can be challenging, as strong emotions may surface during periods of silence [Second, our program structure was based on the principle that the intervention group and active control would have identical contact hours, i.e., 12 h over six sessions. However, the instructors in the project reflected that the caregivers in the active control group were allowed to reflect on and discuss the psychoeducation videos with adequate time allocated for social and emotional support, while for the mindfulness group, the instructors may have felt restricted in spending time to address the emotional needs of the participants, as the mindfulness exercises could have taken up half of the program time. Further studies should pay attention to the development of the program content and ensure that caregivers have adequate time and understand and apply their newly learned knowledge and skills.Third, the expressed emotions and caregiver burden experienced by family caregivers and people in recovery may drastically increase due to the suspension of mental-health care and social services during the COVID-19 pandemic and the increase in family members’ time spent at home. A survey of a Hong Kong Chinese sample reported a high expressed emotion prevalence of 63% among individuals with a diagnosis of schizophrenia, which was much higher than the previous reported prevalence range of 30–40% [Subgroup analysis revealed that male caregivers and caregivers with a secondary or lower level of education had larger improvements in well-being. Male caregivers have been found to have lower caregiver burden at pretest, and they may be more responsive than female caregivers to a brief psychoeducation program. The reason for the better outcomes of caregivers with a lower (vs. higher) education level is unclear. One possibility is that parents in our study who had a higher education level were more likely to invest time and resources in their children’s development and, thus, it was more difficult for them to accept their children’s mental-health challenges. Further studies should explore the relationship of caregiver’s education level with caregiver burden and expressed emotions and the implications in family intervention outcome.The results of analysis of the young adults in recovery in this study partially supported Hypothesis 2. After MBFPE, the young adults reported improvements in over-involvement and hostility with medium effect sizes and an improvement in the level of recovery with a large effect size. Unexpectedly, the young adults reported higher levels of perceived over-involvement, hostility, and overall expressed emotions after their caregivers completed an ordinary FPE, although their recovery score also slightly increased. The time × group interaction effects of the MBFPE and FPE programs were significant in terms of the differences in recovery levels of the young adults and the perceived over-involvement, showing that MBFPE had a superior effect to FPE in promoting recovery and reducing over-involvement. Such findings are consistent with our qualitative data analysis, as many caregivers shared that they learned not to interfere with the young adults in recovery, especially when they felt worried and guilty about the family member’s condition [Although the sample size of the young adults in recovery was small, their perception of the expressed emotions and over-involvement was largely reduced, and their recovery level was found to significantly increase after their caregivers completed the MBFPE program. If we focus on the outcome of expressed emotions, MBFPE played a greater role in reducing over-involvement than in reducing criticism and hostility. A previous Chinese study reported that the over-involvement of caregivers significantly influenced the QoL of individuals with psychosis [