693652

article2017
ISP0010.1177/0020764017693652International Journal of Social PsychiatryHasan and Musleh

E CAMDEN SCHIZOPH

Original Article

International Journal of

The impact of an empowerment Social Psychiatry

2017, Vol. 63(3) 212223
The Author(s) 2017
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schizophrenia: Results of a DOI: 10.1177/0020764017693652

https://doi.org/10.1177/0020764017693652
journals.sagepub.com/home/isp

randomized controlled trial

Abdalhadi Hasan and Mahmoud Musleh

Abstract
Aims: The aim of the study was to assess what empowerment intervention has on people with schizophrenia.
Methods: A randomized controlled trial was carried out between November 2015 and May 2016 involving 112
participants who had been diagnosed with schizophrenia. Patients, who were 18years and above diagnosed with
Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) schizophrenia or schizoaffective disorder from
the outpatient mental health clinics in Jordan, were randomly assigned to take part in an intervention that consisted of
receiving 6 weeks worth of information booklets, with face to face discussions, while receiving their usual medication
or allocated treatment as usual. The participants were assessed at baseline, immediately after the intervention and at
3-month follow-up. The primary outcome was a change in the helplessness score. Secondary outcomes were psychiatric
symptoms, recovery rate, empowerment and quality of life.
Results: This study showed that people with schizophrenia in the intervention group showed more improvement in the
helplessness score immediately post-intervention (F=74.53, p<.001) and at 3-month follow-up (F=75.56, p<.001), they
reported significant improvements in all secondary outcomes.
Conclusion: This study indicated that the empowering intervention was an effective intervention when integrated with
treatment as usual.

Keywords
Schizophrenia, empowerment, recovery

Introduction
Living with psychosis is a very traumatic experience
(Lodge, 2010). Patients do not know what to expect as
psychosis is highly unpredictable and symptoms vary
(Lysaker, Roe, & Buck, 2010). Up until now, there have
been ample studies that have discussed how patients
recover from schizophrenia. Those that have been pub-
lished, however, have demonstrated that a lack of psycho-
pathology in some people with schizophrenia (PwS) can
lead to them living a moderately fulfilling life (Ng etal.,
2008). Nevertheless, most PwS experience psychiatric
symptoms getting worse over time and have relapses
(Chan, Yip, Tso, Cheng, & Tam, 2009).
Many PwS can remain symptom free and others can
lead reasonably productive lives. However, the majority of
them still experience a degree of impairment of function,
and many will suffer relapses or chronic levels of their
positive symptoms (Warner, 2009). The recovery of PwS
means they have gone into remission with psychiatric
symptoms. However, recovery is considered to be a multi-
faceted concept, comprising many different elements, such
as being productive, living independently and sustaining
close relationships with others (Warner, 2009). On the
other hand, most PwS think they have recovered after they
have received healthcare, which leads them to feeling
hopeless and/or helpless (Corrigan, Rafacz, & Rusch,
2011). However, healthcare professionals do not think
about hopelessness or helplessness, rather they think that
PwS are not capable of addressing their own feelings, as
they do not understand their illness (Berry, Allott, Emsley,
Ennion, & Barrowclough, 2014).
The idea of recovery from serious mental illnesses such
as schizophrenia must include both a patients subjective
Mental Health Nursing, Nursing Department, Fakeeh College for
Medical Sciences, Jeddah, Saudi Arabia
Corresponding author:
Abdalhadi Hasan, Nursing Department, Fakeeh College for Medical
Sciences, Alhamra District, Palestine Street, Jeddah 21461, Saudi
Arabia.
Email: aalhasan@fakeeh.care
Hasan and Musleh 213
experiences and measurable objective outcomes (Leamy,
Bird, Le Boutillier, Williams, & Slade, 2011; Slade, 2009).
Traditional clinical definitions of recovery are associated
with individuals returning to a state of normality as experi-
enced prior to the episode of ill health, having found a cure
(Law & Morrison, 2014; National Institute for Health and
Clinical Excellence [NICE], 2009). In the context of mental
illness, recovery is defined as the complete or almost com-
plete remission of psychiatric symptoms and impairments,
and it is not associated with partial improvements in symp-
toms. Meanwhile, recovery as defined by Substance Abuse
and Mental Health Services Administration (SAMHSA) is a
process that may or may not involve symptom reduction and
restoration of function (Rudnick, 2008). Still, others define
recovery as being akin to a clinical recovery, or simply a
reduction of symptoms and role dysfunctions leading to at
least some psychological recovery (Slade, 2009). Another
way of looking at it might be the restoration of patients self
in the world. Recovery-oriented services are increasingly
being called for around the world, and these services do not
consider recovery from mental illness to merely include
symptom remission; they are more interested in individuals
abilities to redefine their selves and to live well, even
where symptoms endure (Soundy etal., 2015). One aspect
of recovery is the development of everyday well-being; this
includes developing environmental mastery, personal
growth, life purpose, increased autonomy, self-acceptance
and positive relations with others (Eisenstadt, Monteiro,
Diniz, & Chaves, 2012; Slade etal., 2014). Several factors
have been identified as facilitating such recovery, including
hope, acceptance of illness, self-responsibility, optimal
treatment and supportive environments (Soundy, Kingstone,
& Coffee, 2011; Soundy etal., 2015).
Recovery in these terms is less about getting rid of
symptoms or problems and more about developing greater
degrees of hopefulness, meaning and purpose in life, along
with a positive sense of identity that goes beyond simply
thinking of oneself as a person with a mental illness
(Andresen, Oades, & Caputi, 2003). Personal recovery has
been described as a journey of growth involving taking
control and responsibility for ones life (Torgalsben &
Rund, 2010). However, many service users rely on a more
subjective definition of recovery, reflecting the process in
which an individuals social identities are developed and
reconstructed, and, to some extent, suffused with the stigma
of the illness identity. This definition has now been widely
adopted by service providers and supports increased par-
ticipation in life, social connectedness, empowerment and
hope (Giusti etal., 2015). Recovery must involve biologi-
cal, psychological and environmental changes, and hence
the range of treatment options available to achieve these
changes is both broad and evolving (Soundy etal., 2015). It
can include pharmacotherapy, case management, cognitive
remediation, family treatment, integrated dual diagnosis
treatment, psychotherapy, skills training and empowerment
intervention, as part of a non-exhaustive list (McCauley,
McKenna, Keeney, & Mclaughlin, 2015).
There is a need for recovery orientation to have inter-
ventions and practices to be carried out in line with the
results of patient assessments (Noh, Choe, & Yang, 2008).
This is in addition to practices that are based on the identi-
fication of the patients own personal strength and capa-
bilities, which will aid in self-efficacy of managing their
own illness and help them regain their place in society and
the community (Davidson, OConnell, Tondora, Styron, &
Kangas, 2006). Thus, it is vital to develop effective inter-
ventions and interventions that can help to improve the
practical and independent well-being of patients (Tolman
& Kurtz, 2010).
In terms of recovery orientation from the Jordanian per-
spective, there are a range of barriers to supporting people
in their personal recovery. A recent qualitative study by
Hasan, Callaghan, and Lymn (2017) reported that schizo-
phrenia is the result of a demonic possession of their rela-
tives mind, prompting them to say or do inappropriate
things. Consequently, they attempted to treat schizophre-
nia by consulting folk exorcists to dispel these spirits. In
fact, Slade (2010) recognized this as an environmental fac-
tor which hinders or delays recovery. Additionally, people
diagnosed with schizophrenia are stigmatized and discrim-
inated against in Jordanian society. Thus, stigma might be
a barrier to individuals with schizophrenia having the
opportunity to develop the valued social roles or more
positive identity that would be considered essential to their
personal recovery (Al-Krenawi & Graham, 2000;
Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2009).
Furthermore, poor infrastructure of the mental health ser-
vice in Jordan has a large impact on the recovery of PwS
(World Health Organization, 2008). Taken together, it has
a direct influence on recovery among PwS in Jordan. In
terms of cultural background, Jordanian families have inti-
mate interpersonal relationships and many interactions
with family members (Abu-Ras, 2003). The findings of the
previous studies indicated that collectivistic culture has
both a positive and negative impact on the schizophrenia
course. However, the negative influence of culture is cor-
related with more severe stigma against mental ill people
and their family relatives when compared with an inde-
pendent culture. Stigma towards mental illness and
unwanted side effects of medication has been reported as
the barriers to recovery (Al-Adawi etal., 2002; Nasir &
Al-Qutob, 2005).
In recent times, scholars have increasingly focused on
the negative effect of schizophrenia on an individuals per-
sonal life, namely, in terms of their family and their work
(Mueser etal., 2001). Subsequently, patients who are in
recovery are more likely to be obedient in their treatment
regime, take their antipsychotic medication and show
moderate functioning (Warner, 2009). Those who have
been diagnosed as suffering from mental illness will
214 International Journal of Social Psychiatry 63(3)
acquire a sense of helplessness if they have to stay in hos-
pital for long periods of time, even if they have been given
the latest antipsychotic medication (Park & Sung, 2013). It
has been found that learned helplessness is a major chal-
lenge in terms of getting patients integrated within their
communities. Directing those who have serious mental ill-
nesses, for example, schizophrenia, to manage their psy-
chiatric symptoms and preventing a relapse at the early
stages, is an efficient way to treat PwS as it helps in their
recovery (Jo, 2009; Shearer, 2009).
Empowerment intervention has been developed to help
empower those who have schizophrenia, in a bid to allow
them to feel they are a part of the treatment process
(Shearer, 2009; Warner, 2009). Empowerment is a con-
struct that links individual strengths and competencies,
natural helping systems and proactive behaviours to social
policy and social change. In health, empowerment empha-
sizes increasing ones sense of ones ability to participate
knowingly in health and healthcare decisions (Rappaport,
1995, 1997). In other words, health empowerment refers to
a health pattern of well-being and a relational process that
emerges from the recognition of personal and social con-
textual resources. Moreover, another definition of empow-
erment emerged from the study conducted by Rappaport
(1997) who defined psychological empowerment as the
connection between a sense of personal competence, a
desire for and a willingness to take action in the public
domain. It is also defined as a process of gaining control
over ones life and influencing the organizational and soci-
etal structure in which one lives. The core features of
empowerment include an ability to decision-making
power, assertiveness, a feeling that one can make a differ-
ence, learning about and expressing anger, not feeling
alone, feeling part of a group, understanding that a person
has rights, growth and change that is never-ending and
self-initiated, increasing ones positive self-image and
overcoming stigma, among others (Slade, 2010).
This process facilitates purposeful participation in the
attainment of health goals and the promotion of individual
well-being (Shearer, 2009). There has been much discus-
sion regarding the need to empower adult schizophrenics
to make informed health decisions and to test interventions
targeting empowerment to promote health among them.
Empowerment intervention in PwS is an especially impor-
tant challenge related to recovery in psychiatric health ser-
vices. However, only a few studies have investigated
psychiatric ward interventions to empower patients,
improve their prognoses and reduce the risk of relapse.
Greater understanding of ones illness and a more positive
attitude towards medication can improve outcomes.
Educational interventions that affect patients attitudes are
likely to have important impacts on psychosocial rehabili-
tation and/or recovery-oriented services (Hasan, Callaghan,
& Lymn, 2015; Slade, 2010; Slade, Amering, & Oades,
2008).
It has been argued that empowerment is a crucial ele-
ment in the recovery process of patients with schizophre-
nia, and this is the reason why mental health services try to
empower PwS (Park & Sung, 2013). Nevertheless, not
much is known about how empowerment can be measured
in an operational sense (Warner, 2009). It is likely that
PwS will feel quite disempowered, however, there are no
studies that have investigated empowerment in these peo-
ple (Chou etal., 2012). Very few studies have examined
outpatient psychiatric interventions that seek to empower
PwS, patients to enhance their prognosis and lessen the
risk of a relapse. It has been found that when a person has
a good understanding of their illness, they are more likely
to react in a positive way to medication, thus there is a bet-
ter chance of recovery (Demoz etal., 2014). However,
there have only been a few studies to date that have exam-
ined outpatient psychiatric interventions that seek to
empower PwS, to enhance their prognosis and to lessen
the chance of relapse. It has been argued that the better
understanding a person has of their illness, the better atti-
tude they will have towards their illness, and this in turn
makes the treatment more successful (Demoz etal., 2014).
Considering the cultural influences of the participants
beliefs and expectation are imperative to devising nursing
intervention, particularly when it is provided in the partici-
pants (Sandy, 2016). Awareness of the cultural beliefs of
the participants is necessary to understand the participants
views on the mental illness and their willingness to col-
laborate with mental health professionals (Diken, 2006). A
recent study conducted by Chien, Leung, and Chu (2012),
who considered the Chinese family and patients beliefs
about schizophrenia and their education needs about ill-
ness, reported a highly significant impact of the interven-
tion on the knowledge level and psychological related
outcomes. For the sake of this study, the characteristic of
PwS in Jordan in terms of literacy level, the content and
method of delivery intervention tailored to acknowledge
participants culture.
Educational interventions that have a positive effect on
the perspective of PwS are very important in terms of the
psychosocial rehabilitation of the patient (Berry etal.,
2014). There is a very limited number of studies which
have investigated the impact of empowerment intervention
on PwS. In addition, the format utilized for the delivery of
interventions to mentally ill people was demanding.
Furthermore, this is the first time that empowerment inter-
vention is used in a developing country such as Jordan.
The objective of this study is to investigate how empower-
ment interventions (nursing interventions) can enhance
recovery from schizophrenia.
Methods
This study was a single-blinded randomized controlled
trial (RCT) to examine treatment as usual alone with
Hasan and Musleh 215
treatment as usual plus an empowerment intervention
comprising of booklets and verbal discussion. The trial
took place in the mental health outpatient department in
Amman, Jordan. These outpatient clinics serve the major-
ity of mentally ill people in Jordan. Ethical approval was
provided by the Ministry of Health.
Participants, recruitment, consent and baseline
assessment
All of the participants were aged 18years or above and had
been diagnosed with schizophrenia spectrum disorder,
based on the Diagnostic and Statistical Manual of Mental
Disorders (5th ed.; DSM-V; American Psychiatric
Association, 2013). The diagnosis for the objective of the
study was reported in the patients medical records, held at
the outpatient clinic. In Jordan, psychiatric diagnosis is
done after a structured interview has taken place between
the psychiatrist and people with mental illness, as well as
family members. All of the participants in the study had to
be capable of reading and writing in both English and
Arabic and had to be capable of providing consent to take
part in the study. People with mental illness with learning
disabilities were excluded from the study, as were those
who had an organic mental disorder, or those who sub-
stance abused. Typically, patients visit the outpatient clinic
on a monthly basis to collect their medications. Patients
eligible to participate in this study were identified by the
duty doctor responsible for prescribing medication and/or
research assistant (RA). Therefore, they were both
excluded from taking part in the randomization process to
minimize bias. The RA contacted potentially eligible
patients to confirm whether or not they met the inclusion
criteria and then invited them to participate in the trial.
Following an explanation of the purpose of the trial and
process of trial involvement, patients were asked whether
they would consent to participate. The participants were
given 2weeks to think and ask about the study. Once writ-
ten consent was obtained, a baseline assessment was
undertaken. This included patient socio-demographics.
Randomization
The participants were allocated on a random basis to one
of the two groups: treatment as usual, or standard plus
empowerment intervention. Each participant was given a
number and then another researcher, who did not have any
contact with the participants randomly allocated them to a
group. A computer was used to generate a random number
list to allocate participants to a study group, at a ratio of
(1:1), generated. Randomization was implemented using a
third remote allocation system. Random list numbers were
sent to the independent researcher of the study. Then, the
RA contacted the independent researcher when recruiting
each participant, to receive an allocation.
The outcome of assessments, both after treatment and
in a 3-month follow-up were also done by an independent
researcher, who was not aware of which group each par-
ticipant had been allocated to. The researcher and the par-
ticipants were told which group the participants belonged
to once they had been allocated. The participants were
given booklets in sealed envelopes in order to reduce con-
tamination and also to ensure the participants remained
anonymous. The primary researcher maintained property
of the booklets so as to avoid distribution to other clinics.
Treatment as usual
Each of the four clinics receives funding from the state and
the care provided by each of them is similar. Every partici-
pant in the study received their usual treatment, which
comprised medication and laboratory examinations which
were carried out by the mental health teams in the clinics.
Intervention
The utilized intervention was adopted from the patient
empowerment intervention for schizophrenia (PEPS); this
was a component of comprehensive rehabilitation inter-
vention directed towards PwS (Hwang, Lee, & Gong,
2006). For the purpose of the study, the intervention was
revised by one psychiatrist and two psychiatric nurses who
had clinical expertise. The intervention consisted of six
sessions. Each session was provided weekly. The number
of sessions was determined based on the average number
of sessions in previous studies conducted through other
formats of psychosocial interventions and reported a posi-
tive result (Hasan etal., 2015; Ran etal., 2003). The inter-
vention discussed six topics classified in three broad
categories: comprehending recovery from an illness, doing
and undoing: efforts made for recovery and the route to the
best recovery. The method of delivering sessions was
through a booklet format supported with face-to-face dis-
cussion. The length of the discussions varied on an indi-
vidual basis and ranged between 20 and 30minutes.
The intervention content was developed based on the
updated psychiatric mental health books and systematic
reviews as well as mental health team perspectives
(Table 1). The final version of the booklet was reviewed by
a small sample of the target population (n=12), as well as
three clinical experts. They examined the content, techni-
cal elements and viability. The booklet came in double
sided A4 format in order for it to be able to fold into three
to enable ease of use; it was printed in colour. Images were
provided alongside the text to aid in comprehension of the
information. The exact timing for the delivery of the inter-
vention was after collecting medication. The intervention
began with a RA welcoming the participants and distribut-
ing the booklet. The RA then went through the booklet
page by page and at the same time provided practical
216 International Journal of Social Psychiatry 63(3)

Table 1. The topics and contents of the empowerment intervention.

Booklet number Topic Contents

One Nature and disease course of
schizophrenia; stigma
Two Weakness and strength of
ability to pursue recovery
Three Challenges to ones life and
things to do with family
members
Four Enhancing communication skills
and management of self-care
Five Drug treatment to improve
long-term outcomes and
Improve drug adherence and
prevent worsening of the
illness
Six Crisis management
Diagnosis of schizophrenia according to DSM-V
Truths and myths about schizophrenia
Symptoms of schizophrenia
How to free oneself from stigma as a schizophrenic patient
Discussing obstacles to recovery in everyday life
Finding individual strength to achieve recovery
Searching for helpful support system
Plan daily schedule for enhancing individual strengths
Seeking support from family members
Learning how to do housework
Learning how to share experiences with family members
Practicing verbal and nonverbal communication in a situation
Maintaining general hygiene on ones own Practicing daily duties
Understanding the importance of continuing with ones medication
Listing therapeutic effects and side effects of medication
Learning medication adherence strategies
Sharing experiences with different side effects of various antipsychotic
drugs
Understanding risks and benefits of every medication
Asking help of family members and health providers
Stress management skills and strategies
Being aware of serious or life-threatening side effects
Correcting problematic situations

advice and answered questions. In order to lessen the risk
of contamination between the two groups in the study,
each participant was given an envelope with a booklet
inserted in it, which they could take away with them.
Outcome measures
The outcome measures were completed straight after the
intervention, as well as 3months afterwards. These were
done by the psychiatric nurse who was blinded to the
group allocation.
Primary outcome measures
The primary outcome used a Modified Learned
Helplessness Scale (MLHS; LHS; Kim, 2005; Quinless &
Nelson, 1998). A LHS is a self-report questionnaire con-
taining 20 items scored using a 4-point Likert-type scale
from strongly agrees to strongly disagree. It is scored
from 20 to 80 with a high score indicating individuals
experiencing higher levels of helplessness. This scale has
been used with people with mental illness and Cronbachs
alpha was .890.906 (Kim, 2005). Cronbachs alpha coef-
ficients of Arabic translated LHS version was .86, and
Content Validity Index (CVI)=86%. This outcome was
chosen to be the primary method as previous studies
showed a strong correlation between helplessness level
improvement and recovery rate and the influence on
empowerment.
Secondary outcome measures
Secondary outcomes were psychiatric symptoms, which
were assessed by a positive and negative Syndrome Scale
(PANSS), recovery rate was assessed by the Recovery
Assessment Scale (RAS) and quality of life rated by
SchizophreniaQuality of Life questionnaire (S-QoL-18)
and empowerment level as rated by the Empowerment
scale.
PANSS measures 30 schizophrenia symptoms; each
clinical symptom is scored from 1 indicating absence of
psychopathology to 7 indicating severe psychopathology,
with higher scores indicating severe psychiatric symp-
toms. Internal reliability and criterion-related validity are
0.77 (positive scale) and 0.77 (negative scale) and 0.52
with the Clinical Global Impression scale (CGI; Kay,
Opler, & Lindenmayer, 1988).
RAS has 41 items measuring life goal, coping ability,
hope and knowledge of support systems. The scale uses a
5-point agreement scale (Giffort, Schmook, Woody,
Vollendorf, & Gervain, 1995). Sample items include I
have a desire to succeed and I can handle it if I get sick
again. A previous study of the scale showed overall scores
to have satisfactory reliability and validity in the United
States (Corrigan, Giffort, Rashid, Leary, & Okeke, 1999).
Cronbachs alpha coefficients of Arabic translated version
of RAS scale was .87, and CVI=86%.
The S-QoL has 18 evaluating eight dimensions:
psychological well-being, self-esteem, family relation-
ships, relationships with friends, resilience, physical
Hasan and Musleh 217
well-being, autonomy and sentimental life. The total
score ranged from 18 to 90 with a higher score indicating
a better quality of life. Cronbachs alpha is .72.84 in
European countries. Cronbachs alpha coefficients of
Arabic translated version of SQoL was .88 and CVI was
0.86%. The empowerment scale was devised by Rogers,
Chamberlin, Ellison, and Crean (1997) and has 28 items
with five subscales including, self-esteem, optimism,
activism, righteous anger and power. Some items of the
scale include I feel powerless most of the time and
People are limited only by what they think possible
(Rogers etal., 1997). Cronbachs alpha coefficients of
Arabic translated version of empowerment scale was .85
and CVI was 0.87%.
Analysis
Sample size
The sample size was estimated based on previous research
which showed a change in the helplessness score of 2
points post-intervention (Park & Sung, 2013). Taking
into consideration a power of 80% and significance level
of p<.05, allowing for 10% attrition, deduced from pre-
vious studies, we estimated 112 participants would be
required.
Statistical analysis
All data were analysed using SPSS Version 23. Analysis
was done by intention to treat with the last observation car-
ried forward to handle missing data at post-treatment and
3-month follow-up. Analyses were carried out blind, with
the groups known as arm 1 and arm 2. Methods of anal- Intervention fidelity was monitored by delivering inter-
ysis such as Intention to Treat analysis (ITT), per protocol
(PP) and ad hoc approaches (imputing worst value in the
control group for intervention group and the best value in
the intervention group for control group) were used to
increase the robustness of and confidence in the study
results. In addition, multiple imputation techniques were
employed to handle missing data. However, the findings
were similar among these approaches. Consequently, the
Last Observation Cariied Forward (LOCF) method of han-
dling missing data was used in this study. Demographic
data were summarized by frequencies and percentages.
Independent samples t-test were used for continuous vari-
ables. The mean scores between groups on all outcome
measures were compared using an independent sample
t-test, as appropriate. To control for type I errors for multi-
comparison tests, Bonferronis adjustment was used to
adjust the level of significance set at baseline for all statis-
tical tests to the 1% level (p<.01). Analysis of variance
(ANOVA; between and within) was used to determine
whether treatment produced between and within groups
and the interactive effects of treatment by time for each
outcome.
Results
Baseline characteristics
A total of 179 potential participants were initially
approached by the RA to discuss potential participation in
the trial. Of these, 112 were identified as meeting the inclu-
sion criteria and were invited to participate in the study.
The remaining 67 did not meet the study inclusion criteria
for several reasons: having a dual diagnosis (n=32), 15
PwS had an intellectual disability and schizophrenia diag-
nosis and five people were illiterate. In addition, 19 par-
ticipants who expressed an interest in taking part in the
study did not return signed consent forms.
Generally, the participants age averaged 36.5years and
the majority of the study sample were male. This is con-
sistent with the nature of Jordanian culture: that is, to hide
females diagnosed with mental illnesses. Over half of
patients attained secondary or a higher level of education.
However, most participants were unemployed. There were
no significant differences in general characteristics
between groups. A total of 112 PwS provided consent and
were randomly allocated to empowerment and recovery
intervention and treatment as usual (TAU; n=56) or TAU
(n=56; Figure 1). Baseline characteristics of participants
are shown in Table 2. There was no statistically significant
difference between the groups on baseline characteristics.
The attendance rate for the first three sessions was 100%.
However, in session number four, two participants missed
the session on the specified time, so their sessions were
rescheduled. Moreover, in the remaining session, one
patient was not able to attend due to logistical problems
and so the session was carried out at a later date.
vention to participants in the same way and the RA con-
ducted all face-to-face discussions.
Intervention effect on the PwS outcomes
Primary outcomes. Exploration analysis was carried out on
the dependent variables at both pre-test and two post-tests
in order to investigate the initial assumption for mixed
between-within subject ANOVA on tests of normality, lin-
earity, multi-collinearity, univariate and multivariate outli-
ers. The homogeneity of variance showed there was no
significant violation of the assumptions (Tabachnick,
Fidell, & Osterlind, 2011). The data from the primary and
secondary outcome of the PwS revealed there were no sta-
tistically significant differences, which is shown in Table 3.
When making a comparison between the participants in
the treatment as usual, those in the empowerment interven-
tion showed statistically significant improvements in LHS
scores, both immediately after treatment and also at the
3-month follow-up. Mauchlys test of sphericity was sig-
nificant (p<.05); therefore, a Greenhouse Geisser correc-
tion for the df value was carried out (Field, 2009). The
218 International Journal of Social Psychiatry 63(3)
Assessed for eligibility (n = 179)
Enrolment
Randomized (n = 112)
Allocated to intervenon (n = 56)
Allocation
Received allocated intervenon (n = 56)
Lost to end of treatment (n = 2)
Parcipants decline to connue (n = 2)
Follow-up
Lost to follow up (n = 1)
Hospitalized (n = 1)
Analysed (n = 56)
Figure 1. Participants progression throughout different stage of the study.
interaction between the groups in terms of time was also
significant for LHS p<.001, univariate eta squared=0.54
(large effect; Field, 2009). A significant time effect was
also shown for LHS (p<.001), univariate eta squared=0.36
(large effect). Furthermore, the result revealed a signifi-
cant group effect (treatment) on LHS (p<.001), univariate
eta squared=0.43 (large effect). This means there is
improvement in the LHS score during the follow-up period
within the empowerment intervention. However, in the
treatment as usual, there was a gradual negative change
during the same time period.
Secondary outcomes. In terms of the PANSS scores, they
revealed a significant reaction between the groups and
time (p<.001), univariate eta squared=0.31 (large effect)
and a significant effect with time was revealed in the
PANSS scores (p<.001), univariate eta squared=0.29
(large effect). The results also revealed a significant differ-
ence in regards to the group effect (p<.001), univariate eta
squared=0.27 (large effect). These results suggest that
taking part in the empowerment intervention is linked to a
Excluded (n = 67)
Not meeng inclusion criteria (n = 37)
Declined to parcipate (n = 30)
Allocated to Control (n = 56)
Received allocated (n = 56)
Lost to end of treatment (n = 4)
No longer interested (n = 3)
Lost a contact (n = 1)
Lost to follow up (n = 1)
Unknown reason (n = 1)
Analysed (n = 56)
Analysis
reduction in the harshness of symptoms at post-treatment
and also at 3-month follow-up.
The results also showed there was significant interac-
tion between group and time (p<.001), univariate eta
squared=0.31 (large effect) and significant effect time was
revealed on RAS scores (p<.001), univariate eta
squared=0.33 (large effect). The results also revealed a
significant difference in regards to the group effect
(p<.001), univariate eta squared =0.21 (large effect).
These results suggest that taking part in the Empowerment
intervention is linked to an improvement in recovery rate
at post-treatment as well as at 3-month follow-up.
The results exhibited there were no statistically signifi-
cant differences between the intervention and the treatment
as usual in the baseline measures linked with SQoL scores.
Mauchlys test of sphericity also proved to be significant
(p<.05) and therefore a Greenhouse Geisser correction, for
the df value was carried out. The interaction between
groups by time was significant for SQoL scores (p<.001),
univariate eta squared=0.34 (large effect). Furthermore,
the group (p<.001), univariate eta squared=0.26 (large
Hasan and Musleh 219

Table 2. Demographic characteristics of PwS in two groups.

Characteristics Empowerment intervention (n=56) Treatment as usual (n=56)

Frequency % Frequency %
PwS
Age, years (M, SD) (37.6, 5.6) (36.9, 6.3)
20 7 12.5 12 21.4
2130 12 21.4 11 19.6
3140 8 14.2 17 30.3
4150 21 37.5 11 19.6
50 8 14.6 5 8.9
Gender
Male 36 64.2 33 58.9
Female 20 35.7 23 41.1
Education level
Primary school or below 15 26.7 14 25
Secondary school 18 32.1 16 28.6
College or above 23 41.2 26 46.4
Employment status
Employed 16 28.6 18 32.1
Unemployed 40 71.4 38 67.9
Marital status
Married 18 32.1 16 28.5
Single 25 44.6 24 42.8
Divorced 7 12.5 7 12.5
Others 6 10.7 9 16.0
Illness duration in years (M, SD) 7.7years (4.3) 8.2years (4.5)
2 16 28.5 13 23.2
35 22 39.2 20 35.7
5 18 32.1 23 41.1

M: mean; SD: standard deviation; : interventional (empowerment intervention) group; : treatment as usual (TAU-standard outpatient care); JoD:
US$1.4.

Table 3. Outcome measure scores at baseline and post-tests results from repeated-measures ANOVA test (grouptime)
between intervention and treatment as usual.

Instrument Empowerment intervention (n=56) Treatment as usual (n=56) Repeated-measures ANOVA

Baseline Post-test 1 Post-test 2 Baseline Post-test 1 Post-test 2 Time Time Group

group

M SD M SD M SD M SD M SD M SD F F F
LHS (2080)a 69.54 8.95 57.34 7.50 50.68 6.6 70.13 6.52 68.78 6.57 76.86 7.48 181.32*** 98.45*** 74.53***
PANSS (30210)b 87.56 10.45 75.56 11.37 66.02 10.43 86.38 12.58 89.59 15.37 86.64 16.83 64.23*** 94.72 *** 37.74***
RAS (26130) 55.45 7.67 78.36 7.87 88.56 9.65 56.37 6.45 55.73 5.89 56.01 6.34 54.34*** 64.78*** 78.45***
SQoL (1890) 47.65 5.78 58.34 4.76 63.43 6.34 48.03 6.65 49.46 5.86 50.50 5.74 39.56 *** 88.78*** 26.58***

: intervention (empowerment intervention) group; : treatment as usual (standard outpatient care); M: mean; SD: standard deviation; LHS: Learned
Helpless Scale; PANSS: Positive and Negative Syndrome Scale; RAS: Recovery Assessment Scale; SQoL: SchizophreniaQuality of Life; Post-test 1:
immediately post-intervention; Post-test 2: 3-month post-intervention.
aPossible range of scores of each scale indicated in parenthesis.
bPossible range of scores of each scale indicated in parenthesis.

***p<.001.

effect) and time effect (p<.001), univariate eta squared= Interestingly, the findings indicated there was signifi-
0.35 (large effect) were statistically significant for SQoL cant interaction between group and time (p<.001), univari-
outcome. ate eta squared=0.27 (large effect) and significant effect
220 International Journal of Social Psychiatry 63(3)
Awareness of
schizophrenia
Improve coping
and engagement Reduce
Empowerment
in intervenon psychiatric
Reduce
symptoms,
improve
Helplessness recovery
Internalised Social interacon
sgma
Figure 2. Potential impacts intervention.
time was revealed on empowerment scores (p<.001), uni-
variate eta squared=0.26 (large effect). The results also
revealed a significant difference in regards to the group
effect (p<.001), univariate eta squared=0.18 (large effect).
These results suggest that taking part in the empowerment
intervention is linked to an improvement in empowerment
level at post-treatment, as well as at 3-month follow-up.
Discussion
To the best of our knowledge, this study was the first RCT
utilizing a helplessness and recovery empowerment inter-
vention targeted at PwS to promote recovery at a national
and an international level. Furthermore, it is the first of
such a study to be carried out in the Middle East. Overall,
the model presented in Figure 2 explains trial results
reduction in helpless and its impact on other measured
outcomes at post-test 1 and post-test 2. In part, the model
explains how empowering PwS is associated with a reduc-
tion in psychiatric symptoms, improving empowerment
levels and improvement in recovery rate. It indicates that
internalized stigma moderates the effect of awareness of
schizophrenia on the hope and self-esteem of PwS patients.
This is consistent with the findings of this study, suggest-
ing that benefits from the psychiatric treatment and reha-
bilitation interventions are related to the meanings people
assign to both their illness and the treatment itself
(Pijnenborg, Van Donkersgoed, David, & Aleman, 2013;
Tait, Birchwood, & Trower, 2003). Notably, rejecting
social and self-stigma among participants may have led to
a sense of hope and confidence about the possibility of
recovery and changed other negative self-evaluations. This
in turn may lead to high engagement in the intervention
and treatment and a tendency to use effective coping strat-
egies (i.e. reassurance, persuading or seeking support from
others) to deal with schizophrenia symptoms and stressors.
These changes may have improved their social contacts.
Simply put, the process of accepting and internalizing
social stigma changes the way people perceive and feel
about themselves and their likelihood to plan and meet
their life goals, and consequently leads them to avoid oth-
ers and experience depression.
This study results revealed that the intervention was
effective in reducing feelings of helplessness among par-
ticipants who received intervention straight after the
intervention and 3months afterwards. These results are in
agreement with those obtained in earlier studies (Kim,
2005; Park & Sung, 2013; Warner, 2009). As a result, the
study results supported the hypothesis that participants
who received intervention would show less helplessness
post-intervention immediately and at 3-month follow-up
in the hopelessness and recovery of empowerment inter-
vention compared with treatment as usual. In turn, this
would improve recovery and quality of life as well as
empowerment level. Chronic PwS showed growing feel-
ings of helplessness compared with acute PwS (Lodge,
2010). This finding may be potentially justified in that
chronic PwS experience recurrent hospitalization which
might be erosive and limit his or her ability to achieve their
life plan. They might also be more accepting of prejudices
and internalizing it all to themselves, leading to feelings of
shame and alienation. A further analysis was carried out to
compare the intervention effectiveness on acute and
chronic PwS. It demonstrated a significant improvement in
the recovery and helplessness outcome among acute and
chronic PwS. It seems that the intervention helped PwS
manage their condition and provided them the courage to
confront stress and stigma. Furthermore, in this study,
empowerment modified the way participants perceived
their illness, and encouraged them to take more control
over negative events and to handle internalized stigma bet-
ter, which may in turn have led to their improved well-
being (i.e. being less stressed and more optimistic).
There are a limited number of studies that have exam-
ined the effectiveness of helplessness and recovery
empowerment intervention. This renders comparison and
contrast hard. On the other hand, studies tested other forms
of psychosocial interventions such as psychoeducation in
Jordan and demonstrated its effectiveness (Hasan etal.,
2015). This study findings confirm that adding such an
intervention to standard healthcare in psychiatric clinics is
an effectual method to ameliorate the severe symptoms of
schizophrenia (Baggaley, 2008; San etal., 2012). A possi-
ble explanation for this might be that the intervention
instilled accurate information about illness, which might
enhance their insight of the illness and help PwS devise
coping strategies as well as change their attitudes towards
antipsychotic medication (Mui & Huiting, 2015). This
might result in creating a low stress environment through
being vigilant about stressor triggers, which might have
also led to a further reduction in psychiatric symptoms and
improved recovery and helplessness levels. Unfortunately,
a further study needs to be carried out to measure this
intervention effect on insight and medication compliance.
The results of this study largely support those of previous
studies, showing that an empowerment of PwS was an
important factor in encouraging them to continue taking
their drug treatment after discharge; it might potentially
play a key role in reducing relapse rate in the hopelessness
and recovery of empowerment intervention participants
Hasan and Musleh 221
immediately after the intervention and at 3-month follow-
up. As a result, it possibly reduced helplessness (Suzuki,
2007; Vauth, Kleim, Wirtz, & Corrigan, 2007). A further
study is needed to examine the relationships between
empowerment intervention on relapse rate, self-esteem
and medication compliance.
It was revealed that having knowledge about the illness
was the most significant route to patients having a positive
attitude, which suggests that adherence focused psychoe-
ducation should be implemented into the everyday care of
patients at clinics for better long-term outcomes (Boyer
etal., 2012). Non-adherence to antipsychotic medication
was noted to be a significant factor in reducing PwS self-
esteem. Additionally, the knowledge obtained from the
intervention empowerment enabled them to cope with
their psychiatric symptoms, rather than adopting an avoid-
ance coping strategy (Boyer etal., 2012). Another intrigu-
ing point is that the empowerment intervention provided
social support through better understanding of their illness.
Consequently, they changed various home environment
stressors that may have contributed to further reducing
the severity of psychiatric symptoms. Chou etal. (2012)
demonstrated that the severity of the psychiatric symptoms
is the main factor that negatively affected the QoL and
impeded recovery rate among PwS.
What the study adds to the
international evidence
The findings of this study are important, as this interven-
tion is the first time this intervention has been tested in
Arabic-speaking countries and used an innovative method
of delivering intervention. Moreover, this study is the first
international or national study to utilize an RCT to exam-
ine the effectiveness of an empowerment intervention.
Such a study design is generally considered to be the gold
standard in comparing and evaluating different treatments
(Craig etal., 2011). The design of the study was influenced
by a pragmatic approach; the study reflected the real
world as the research team did not test a specific theory
and the findings were meaningful for a clinical setting. In
addition, the study was designed and conducted in accord-
ance with the Consolidated Standards of Reporting Trials
(CONSORT) statement guidance for trials of this nature
(Schulz, Altman, & Moher, 2010).
The pragmatic approach allowed for the inclusion of
participants that are typical of PwS to be treated and sup-
ported in a current clinical practice, which might have max-
imized the generalizability of the findings. For example,
the study did not exclude participants who had only been
diagnosed with schizophrenia for a short time, or those who
refused to take medication. Although RCT is a robust
research design, this study has some weaknesses. First, the
research team was not able to report the type of antipsy-
chotic medication because prescribing of medication relies
on the preferences of the psychiatrists and lack of the avail-
ability of antipsychotic medication in Jordan. This implies
that the level of medication does not necessarily relate to
the level of illness as a PwS patient could be on a higher
dose but also be functioning well. Moreover, psychometric
properties of the utilized outcome measures are not estab-
lished yet.
Conclusion
To the researchers knowledge, this study is the first rand-
omized control study that has examined helplessness
recovery empowerment intervention, delivered via book-
lets, both globally and in the Middle East, which has
investigated a wide array of outcomes. This format of
delivering intervention is less demanding and accessible
and more accepted by mentally ill people. This study
revealed that the empowerment intervention was superior
in decreasing individual helplessness, improving recovery
rate, decreasing psychiatric symptoms and improving
quality of life. This study has also demonstrated that inter-
vention content and method of its delivery was acceptable
and can be easily carried out by psychiatric outpatient
clinics. The study revealed the possibility of including
empowerment interventions as a part of an inclusive psy-
chosocial intervention.
Acknowledgements
Trial registration: NCT02968667.
Conflict of interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship and/or publication of this article.
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