British Journal of Psychiatry (1996), 168, 199204

The Impact of Education Groups for People with

Schizophrenia on Social Functioning and Quality of Life
JACQUEUNEPA.
ATKINSON,
DENISE
A.COIA,W.
HARPERGILMOURandJANICE
P.HARPER
Background. Education groups for people with schizophrenia have tended to concentrate on
compliance with medication.This study examines impact on social behaviour and quality of life.

Method. A catchment-wide service was set up for community-based patients. Patients who
indicated an interest in education groups were randomly allocated to either an education group
or a waiting list control group. Those who attended groups were compared with the control
group.
Results. About one-quarter of community-based patients showed interest in attending edu
cation groups. Those who attended showed no change in mental state or compliance with
medication (already high) but significant gains in quality of life,social functioning and social
networks.
Conclusions. For patients who choose to attend education groups significant gains in social
functioning and quality of lifeare possible without specific skils training.

Despite widespread interest in psychoeducation

programmes for relatives, there has been little
investigation of the effects of providing education
about their illness to people with schizophrenia.
Care must be taken

to distinguish

education, most studies do not employ control

groups and rely on anecdotal evidence (Greenberg
et a!, 1988; Williams,

programmes

which take a psychoeducational approach to skill

deficit from those simply presenting information
about the illness.
An early study (Maihotra & Olgiati, 1977) invited
patients being treated with fluphenazine enathate to
attend a fiuphenazine
group', together with any
interested family or friends, to discuss and monitor
aspects of medication,

including

side-effects.

1989; Lebrun et a!, 1991).

These studies indicate that people with schizo

phrenia areable to learnand understand information
relevant to their condition, although Smith et a!
(1992) suggest that patients' pre-existing,
idiopathic
concepts of their experiencesmay be incompatible
with the illness concept of schizophrenia. They
compared patients who had residual symptoms with
those who did not, and found greater increases in
information

among

those who did not, but no

significant changes in insight or compliance with

medication for either group. Compliance with

Since

then a number of studies have studied the effect of

education on compliance (Powell eta!, 1977; Seltzer

medication

et a!, 1980; Pilsecker, 1981; Kelly & Scott, 1990), all

indicating improved compliance, while some have
incorporated
education in wider skill and self
management programmes of which compliance is

a part (Eckman et a!, 1992). Allied to compliance

have been studies focusing on teaching patients
early warning signs of relapse (Hen & Melville,
1980) and the effects of medication (Wallace et a!,

has been

of interest

because

of its

relationship with relapse, but the effects of education

beyond compliance have been neglected. Smith et a!
(1992) suggest that the crucial issue is not just
whether greater knowledge affects clinical outcome
but also whether it has beneficial
effects upon...
individual well-being.The aspect of quality of life
which has received most attention is social function

ing, which has been related to poor outcome (DeJong

1985).

et a!, 1985). Set against this clinical picture of skill

Other education programmes look at aims and

outcomes other than compliance. The first to

deficit the user movement has emphasised the need

for patients to be given information so as to be able to
make informed choices.
To this end we set out to investigate whether
giving people with schizophrenia information about
their condition would have any effect on quality of
life, specifically social functioning. Since it was

employ

a control

group

(Goldman

& Quinn,

1988) reported that patients who attended a three

week education programme showed significant
gains in information and reduction in negative
symptoms. Although interest remains in patient

199

200

ATKINSON ET AL

unclear which patients might benefit the most, a

community-wide study was planned.

Method
Study population
A register of patients with schizophrenia living in

maintaining many people with schizophrenia

in
therapy, or even in touch with services, made a
placebo'
intervention to control for social interac
tion inappropriate. This design has been used
previously (Kelly & Scott, 1990).
Patient interviews and assessments were carried
out pre-group, post-group and at three months

follow up.

the community in south Glasgow was already in

existence from a previous study and was updated,
giving a total population
of 515. This was a
reduction from 823 when addresses and diagnosis
were confirmed. It does not include people who are

Assessment measures

currently long-stay hospital patients or those not

Overall & Gorham, 1962), the Krawiecka Assess

known to psychiatric

ment Scale (Krawiecka et a!, 1977) and the Global

Assessment Scale (GAS; Endicott et a!, 1976).
Quality of life (QOL) was assessed using Heinrichs
et al's scale (1984) and social functioning using the
Social Functioning Schedule (SF5; Remington &
Tyrer, 1979) and a modified Social Network

services (mainly people who

receive all treatment via their GP). It is worth

noting that there were very few patients from ethnic
minority groups, despite the existence of sizeable
Asian and Chinese communities in the area.

Schedule (SNS; Dunn et a!, 1990). Knowledge of

Contact
Patients were contacted
by letter in the first
instance. Concerns over patient's awareness of their
diagnosis meant the word schizophrenia was not
mentioned in the letter, and the full nature of the
groups was not disclosed. Patients were invited to
agree to an interview at home (or clinic) to discuss
the new service. Patients who did not agree to meet
with

Mental state was assessed by a psychiatrist (DAC)

using the Brief Psychiatric Rating Scale (BPRS;

the researcher

(JH)

at this

stage

were

thus

unaware of the full nature of the service they were

declining. The groups were discussed in detail at
this interview and three attempts were made to
contact the person at home before they were

schizophrenia and self-esteem were also assessed

but will not be reported here. Compliance with
medication was assessed at nine months follow up.
Patients were given the choice of where they wanted
the assessments carried out, their own home, the
day hospital or a community clinic.

The education groups

Groups were run in each geographical area at a
time convenient to patients. They were held in
community settings including community centres,

deemed to have rejected the group.

unemployed workers centres, health service pre

mises and Salvation Army premises. All had cafs

Design

available and funds were allocated for coffee and

snacks. Group leaders were mainly CPNs but
included an occupational therapist and a registrar.

Diagnosis was confirmed by a psychiatrist (DAC)

using Schedule for Affective Disorders and Schizo
phrenia

(SADS)

(Mannuzza

et a!, 1985) and DSM

lIlR
(American PsychiatricAssociation, 1987).Ten
geographical areas, each containing approximately
50 patients, were delineated, it being estimated that
each area would give one education group (of
approximately
10) and one control group. Even
tually eight geographical groups were formed, with
some attempt to put patients of similar functioning
together. Random allocation to education group or
waiting list control group occurred after this had

been done. Patients who were allocated to the control

group were told the groups were currently full and
they would be offered a place later.

It was decided to use a waiting list control group

as the education group was an additional, rather
than a replacement
service. The difficulty of

All received training to run the groups.

The groups ran for 20 weeks, each session lasting
about an hour-and-a-half,
including a break for
coffee and snacks. Sessions alternated between an
information session (short presentation and discus
sion) followed by a problem-solving
session.
Patients were given a manual outlining the content
of the sessions (Table 1).
Statistical analysis
Changes over time within the group attenders were
tested for significance using paired 1-tests. Compar
ison of group attenders and controls at the same
point in time and comparison of changes over time
between group attenders and controls were made

using two sample 1-tests. Where the assumption

of normality

was

dubious,

the

corresponding

201

EDUCATIONGROUPSFOR SCHIZOPHRENIA
Table1

patients most likely to accept a place were those

with a middle length illness (914years) of whom
40% accepted. Of those with less than five years

Topicscoveredineducationgroups
1 Whatdoesschizophrenia
meantoyou?
2 Whatisschizophrenia?

illness (bottom quartile) 29% accepted and of the

top quartile (more than 15 years ill) 26% accepted

3 Problem
solvingmanageig
symptoms
4

(x2=17.3,P=0.008).Outcome
ofpriorillnessfor

Treatmentofschizophrenia

5 Problem
solving-medication
andusside-effects
6
7

RehabihtatioriCommunityresources
Problemsolvingemployment,
leisure

8 Earlysignsofrelapse
9

Problemsolvingmana@ng
relapseandsymptoms

10 Whatcauses
schizophrenia?
11 Problemsolving-usingalcoholandotherdrugs

12 Fanikes
andschizophrenia
13 Problem
solving-relations
withthefanily,
managing
negative
feelings

the 146 accepting was rated as: complete return to

functioning 6%; mild chronic 34%; moderate
chronic 34%; and marked chronic 25%. Suicidal
gestures or attempts had been made by 40% of
patients, this being rated serious in 12%. The
majority (64%) were single with 15% separated,
widowed or divorced and 21% currently married!
co-habiting.

Seventy-three

per cent of men had

14 Relating
toother
people-famll@
friends
andothers

never married compared to 47% of women

15 Problem
solving-social
skille,
assertiveness,
tellingpeople
about

(@2=

yourillness

10.9,

P=0.004).

Only

one

person

was

cur

rently in work and 73% had not worked at all since

the onset of their illness.

16 Stress
17 Problem
solving-stress
management,
withdrawal

18 Usingservices

Impact of groups

19 ProblemsoMnghousing.social worlcveluntaryagendes, legal

aspects
andpatient's
rights

20 Wheredoyougofromhere?
non-parametric tests were used to confirm the
results of the t-tests. In all cases the non-parametric
tests gave similar results to the I-tests.
Results
Group acceptance
Of the 515 people on the register 146 (28%)
accepted a place in a group of whom 73 were
randomly allocated to education groups and 73 to
the control condition.
Of those accepting, 63% were men and 37% were
women, the same ratio as on the register. The

Despite agreeing to attend a group 16patients did not

attend at all so data is presented for those attending
groups(n = 57), ratherthan those allocated to groups.
We have included in the data analysis people who
attended some but not all group sessions.
Quality of l@fe

At baseline there was no difference between groups

on total quality of life scores but at post-group
there was a significant improvement in group
attenders (mean score: group attenders 68.5,
controls 60.3; t = 2.45, P= 0.02) which was main
tained at follow-up (mean score attenders 67.9,
controls 58.2; t=2.53, P=0.01) (Table 2). Compar
ison of changes from baseline scores show that
attenders have a significantly greater change in

Table2

Meantotalscoresof assessments
nPre-groups.dnPost-group&dnFollow-ups.dQuality
oflife
controls
20.7Social
attenders73

5759.8 62.418.017.161

5360.3 685'11618.957

5158.2
6@919.0

522.6

502.52.0'1.2

FunctioningSchedule

controls
11Social
attenders73

572.9

2.52.5 1562

2.4t3

t358

NetworkSchedule-btal contacts
controls

10.7-.
attenders73
sigreticant

at 0.05;, sigmflcant

5713.3 13.19.7 6.560

at 0.01.

5213.1 118'10.38.656

5013.5
17.510.8

ATKINSON ET AL

202

scores over time than controls at post group (mean

mean number of friends 2 (minimum 0, maximum
change in scores, attenders + 6.5, controls 0.5; 13).
t = 3.2, P = 0.002) and follow up (mean change in
For those attending groups there was a signifi
cant increase in the total number of contacts (mean
scores, attenders + 5.6, controls
2.5; t = 3.1,
pre-group 13, post group 17; t = 2.0, P = 0.05). The
P= 0.002).
The four factors in QOL can be looked at
increase was of a similar magnitude at follow up but
it was not quite significant (mean 17, t = 2.0,
separately. Factor 1 (Interpersonal relations and
social network) shows attenders have a significantly
P = 0.06), due to a drop in number of those
greater increase in their scores over time than do
available for assessment. There was no significant
controls, indicating an improvement in relations
increase in contacts in the control group. There was
and networks at post group (mean change in scores:
a significant difference between group attenders and
attenders +4.3, controls 6.0;
t=3.7, P0.000l)
controls in the mean change in the total number of
contacts at post group (mean change attenders
and follow up (mean change in scores: attenders

+4.0, controls 2.
0; z3.l,

P0.002).

Factor 2

(Instrumental role functioning) which relates to

employment and Factor 3 (Intrapsychic founda
tions) which relates to mental state show no
significant differences. Factor 4 (Common objects
and activities) relates to possessions and daily
activities and shows a significantly greater increase
in scoresforgroup attenders
than forcontrolsat
postgroup (mean changeinscores:
attenders
+ 7.0,
controls
1.0;t= 2.1,P = 0.04),but thiswas not
maintained at follow up.
Social FunctioningSchedule
There was no significant difference between group
attenders and controls at baseline on average social
functioning score and this did not change at post
group (Table 2). At follow up, however, there were
significant differences between attenders and con
trols (mean score, attenders 2.0, controls 2.5;
=

2.1,

0.004)

in

the

direction

of

attenders

having higher social functioning. There was no

significant difference between groups at post
group on mean change in scores over time but
there was a significantly greater increase in
functioning at follow up for group attenders
(mean change in scores: attenders
0.6, controls
0.06;
t=2.l, P=0.04).
Social Networks Schedule (Mod@fIed)
At baseline there was no significant difference
between group attenders and controls (Table 2).
The mean number of total social contacts was 13,
with a range from 1 to 66. The mean number of
daily contacts was 4 (minimum 0, maximum 22),
mean number of weekly contacts8 (minimum 0,
maximum 56) and mean number of monthly
contacts 1 (minimum 0, maximum 10). There were
no significant differences between the groups in
type of contacts. The mean number of relatives was
3 (minimum 0, maximum 12), mean number of

confidants 3 (minimum 0, maximum 17) and the

+ 4.0, controls 1.0;

t=4.4

P=0.0001)

and at

follow up (mean change attenders + 4.5, mean

change controls 4.0
t = 3.6, P= 0.0001).
The number of friends or relative contacts for
group attenders did not change significantly but the

number of confidants did increase significantly at

post group (mean number of confidants pre-group
3.8, post group 5.1; 1=3, P=0.004)
and was
maintained at follow up (mean number of con
fidants 5.1; t = 2.8, P = 0.006). The difference
between group change over time is significant and
maintained from post group (mean change atten
ders + 1, controls 1,;
t = 2.8, P= 0.007) to follow
up (mean change attenders + 1, controls 0; t = 2.5,
P=0.02).
Mental state
There were no significant differences at any time
between groups, nor were there any significant

changes over time.

Compliance with medication
Data from medical records on medication was
incomplete for 36% of patients. For those patients
on depot medication
for whom records were

available (n = 73) average compliance rates were

generally very high (95% pre-group and 96% post
group). Fifty-nine per cent had a compliance rate of

100% pre-group and 80% had a compliance rate of

90% or above. It could not be expected, therefore,
that the groups would have any overall impact on
compliance. Good attenders did, however, show an
average increase in compliance of 2%.
Discussion

Response rate
Although the interest in the groups could be seen as
low, a response rate of about a quarter in a total

community population is not out of line with the

EDUCATIONGROUPSFOR SCHIZOPHRENIA
major US study (Kelly & Scott, 1990). Some people
actively rejected the groups as unnecessary as they
were doing
airight' while others refused by
avoiding the researcher, having received the original
letter. The difficulty of getting some patients
involved in any form of treatment/rehabilitation is
well known, and we did not go beyond three visits
to the person's home in trying to contact them to
avoid accusations of harrassment. Although all the
people contacted had a clear diagnosis of schizo
phrenia all were not necessarily in current contact

with services. Other studies have concentrated on

people with whom they have current contact,
including in-patients (Powell et al, 1977; Pilseker,
1981; Goldman & Quinn, 1988; Greenberg et al,
1988; Kelly & Scott, 1990).
Impact on mental state
It was not expected that education groups would
affect mental state and neither examination of
mental state nor the intrapsychic foundations factor

of the Quality of Life scale showed any significant

change. Only two people reported finding the
content of the groups upsetting and dropped out
for this reason.

Compliance with medication

Compared to other studies, compliance with
medication in this group of patients was high
(which might reflect our recruitment strategy) and,
therefore, could not realistically be expected to
improve. Patients coming to groups were good
depot clinic attenders (but not all depot clinic
attenders came to the groups). Any changes which
occurred in those attending groups could not,
therefore, be attributed to improvements brought
about by increased medication.
Quality of life and sodal functioning
The improvements in quality of life come mostly
from improvements in interpersonal relations and
expanding social networks (factor 1) and would
seem to be supported by the significant differences
shown in the Social Functioning Schedule and the

Social Networks Schedule. The social networks

data would seem to indicate that the quality of
relationships was changing, not just the number of
contacts, as group attenders reported significantly
more confidants.
The relationship between social functioning and
social networks is complex and it would be difficult
to say whether greater social functioning leads to a

wider social network or vice versa from this data. It

203

is worth noting, however, that the changes in

quality

of life cannot

simply be attributed

to the

social aspect of the group and increased contact. If

this was the case we might expect to see those
patients whose quality of life improved to have had
low levels of social contact at baseline. This is not
the case. Of those with the greatest increases in
quality of life 31% had 16 or more contacts at
baseline (the top quartile of social contacts). Using
rank correlations there is no correlation between
the total number of contacts at baseline and change
in quality of life scores at either post group
(r= 0.1)or

at

follow

up

(r= 0.06).The

maintenance of increases at follow up indicate that

the change was not dependent on the contact in the
group, but that such improvements persist.
It is difficult to get a real sense of the actual
impact and diversity of the changes on individual's
lives without resorting to anecdote. One group of
withdrawn and isolated youngish men decided they
wanted a holiday. In the past inclination had been
missing, now the issue was finances. They applied to
a mental health charity on their own initiative and
were awarded a grant which allowed them to take a
camping holiday on Arran. Several women from
another group continue to meet regularly in a coffee
shop on a Saturday morning simply for a chat.
Several young men used to go to the pub together

and then use the structure of the group discussion

time to discuss problems and each other's beha
viour. They were able to put this in a context of
this
looks normal' and this
looks ill'.
The groups did not attempt to teach social or
other daily living skills, nevertheless very real
changes in social functioning, social networks and
quality of life resulted. Why this occurred is
unclear. The increases in social networks was not
simply a result of contact with the group members.
To compare education groups with social groups
would prove difficult as many people with chronic
schizophrenia reject social interaction. Lack of
interest in new services can be seen in the number
of patients with whom the research assistant was
unable to make contact, despite repeated letters and
home visits, and the number who returned the
initial response slip indicating they wanted no
involvement without knowing what the new service
was.
Within the groups patients were encouraged to
think about how their illness influenced their lives
and how they might be able to use knowledge about
their illness to take greater control of their lives. It
may be that this framework allows patients to
rethink and reframe some of their behaviours and
put into practice dormant skills. This may also

ATKINSON ET AL

204

account
for the increases in the number of
confidants
reported, indicating that the group
members were able to have closer relationships

psychiatric disturbance. Archives of General Psychiatry, 33,

766-771.
GOLDMAN, C.

with others than previously. Whether this service

could be extended to a wider range of people with
schizophrenia may depend more on the ability to
get poorly motivated people to attend than the
content of the groups themselves.

R. & Qurr'm@, F. L. (1988)

Effects

of a patient

education programme in the treatment of schizophrenia.

Hospital and Community Psychiatry, 39, 282286.
GREENBERG,

L.,

Fmia,

S.

B.,

COHEN,

C.,

et

al

(1988)

An

interdisciplinary psychoeducation programme for schizophre

nia patients and their families in an acute care setting. Hospital
andCommunityPsychiatry,39, 277281.
HErNRICHS, D. W., HANLON, T. E. & CARPENTER Jr., W. T. (1984)

The quality of life scale: An instrument for rating the

schizophrenic
388398.
HERS,

Clinicalimplications

Educationgroupsfor peoplewith schizophrenia

M.

deficit

syndrome.

Schizophrenia

I. & MELVILLE, C. (1980)

American Journal ofPsychiatry,

KELLY, G. R. & Scorr,

Relapse

10,

in schizophrenia.

137, 801805.

J. E. (1990)

Medication

health education among outpatients

have a positive impact on social functioning, so

Bulletin,

compliance

and

with chronic mental

disorders. Medical Care, 28, 11811

197.

cial networks and quality of life.

K@wiscv@,

The intervention involvedno specific skillstraining.

The groups were most acceptable to patients with

high compliance with medication.

M.,

GOLDBERG,

D.

&

VAUGHAN,

M.

(1977)

standardized psychiatric assessment scale for reporting psycho

tic patients. Acta Psychiatrica Scandinavica, 55, 299308.

LEBRUN,

L.

J.,

LELANDER-SINGH,

M.

&

Luica

A.

(1991)

Schizophrenia outpatient education. Canadian Nurse, May,

2527.

Limitations

Only a minority

of patients

were

interested

MALHOTR.A, H. K. & OLGIATI, S. G. (1977) Fluphenazine

in groups. Comprehensive
Psychiatry,
18, 8992.

in

groups@

The role of increased social contact in the groups

is a confounding variable.

MNuzzA,

The groups

OVERALL, J. E. & GORHAM, D.

require comparisons

therapy

S., FYER,A. J. & KLEIN,D. F. (1985) Schedule for

Affective
Disorders and Schizophrenia
L(fetime
Version.
National Institute for Mental Health. Grant MH2141I.

with other types

R. (1962)

The

Brief

Psychiatric

Rating Scale. Psychological Reports, 10, 799812.

of patienteducationwhich need to be developed.

PILSECKER,

about

C.

(1981)

Hospital

classes

educate

schizophrenics

their illness. Hospital and Community

Psychiatry,

32,

60-61.
POWELL, B. J., OTHMER,

References
AMERICAN

PSYCHIATRIC

AssociAtioN

E. & SINKHORN, C. (1977)

Pharmacolo

gical aftercare for homogenous groups of patients. Hospital and

Community Psychiatry, 28, 125127.
REMINGTON,
(1987)

Diagnostic

M.

&

TYRER,

P.

(1979)

The

social

functioning

schedule
A brief semi-structured interview. Social Psychiatry,

and

14, 151157.
Statistical
Manual of Mental Disorders(3rd edn, revised)
SELTZER, A., RONCARI, I. & GARFINKEL, P. (1980) Effect of patient
(DSM-IIl-R).
Washington, DC: APA.
education on medication compliance. Canadian Journal of
DEJONG, A., GIEL, R., SLOOF, C. J., et at (1985) Social disability
Psychiatry, 25, 638645.
and outcome in schizophrenia patients. British Journal of
SMITH, J., BIRCHWOOD, M. & HADDRELL, A. (1992) Informing
Psychiatry, 147, 631636.
people with schizophrenia about their illness: The effect of
Dimmi, M., O'DIuscoLL, C., DAYSON,D., et al (1990) The TAPS
residual symptoms. Journal of Mental Health, 1, 6170.
project 4: An observational study of the social life of long stay
WALLACE, C. J., BOONE, S. E., DONAHOE, C. P., et al (1985)
patients. British Journal of Psychiatry, 157, 842848.
Psychosocial rehabilitation for the chronic mentally disabled:
ECKMAN, T. A., WIRSHENG, W. C., MARDER, S. R., et al (1992)
social and independent living skills training. In Behavioural
Techniques for training schizophrenic patients in illness self
Treatment of Adult Disorders (ed. A. Barlow), pp. 462501.
management: A controlled trial. American Journal of
N. Y.: Guilford.
Psychiatry,149, 15491555.
ENDICOTT, J., SPITZER, R. L., Fwss,

J. L., et al (1976)

The global

WILLIAMS,

assessment scale. A procedure for measuring overall severity of

Jacqueline M. Atkinson, PhD, Department

MRCPsych,

Community

and Mental

Health

C.

A.

(1989)

Patient

education

for

people

with

schizophrenia. Perspectives in Psychiatric Care, 25, 1421.

of Public Health, University of Glasgow; Denise A. Coia,

Trust,

Glasgow;

W. Harper

Gilmour,

MSc, Janice

P. Harper,

BA,

Department of PublicHealth,University
of Glasgow
Correspondence: Dr J. M. Atkinson, Department of Public Health, University of Glasgow, 2 Lilybank Gardens, Glasgow
G12 8RZ. Fax:0141 330 5018
(First received 27 March 1995,final

revision 22 August 1995, accepted 18 October 1995)

The impact of education groups for people with schizophrenia on

social functioning and quality of life.
J M Atkinson, D A Coia, W H Gilmour and J P Harper
BJP 1996, 168:199-204.
Access the most recent version at DOI: 10.1192/bjp.168.2.199

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