The present study is a quasi-experimental study and the population of the study consisted of all caregivers of clients with bipolar disorder who referred to Ghods Psychiatric Hospital in Sanandaj in 2019. The sample size was measured, according to the study of Seyedfatemi et al. (Seyedfatemi2, Ahmadzad Asl, Bahrami, & Haghani, 2019), and taking into account the error propagation (α = 0.05), test power (β = 0.9) and the probability of a 10% dropout for the samples and with using the following equation, 32 person in each group was considered.
Conditions for caregivers to enter the study included the age of 18 and above as well as the Consent of the client's treating physician. The condition for the caregiver included spending the most caring time for the client, lack of mental retardation, lack of drug and alcohol consumption, minimum age of 18 and the maximum of 65 years, lack of vision and hearing impairment, and complete satisfaction to participate in the research. The exclusion criteria were withdrawal from further research and non-participation in at least two sessions of the training program.
The data collection tool consisted of two questionnaires. The first questionnaire was the demographic characteristics of the subjects, including age, gender, marital status, education, occupation, economic status, the number of family members, caregiver-client relationship, history of the patient's disease, family history of the disease and the number of times the patient was hospitalized. The second questionnaire was the Connor-Davidson Recovery Questionnaire (CD-RISC).
The Connor-Davidson Resilience Questionnaire consists of 25 items designed by Connor and Davidson in 2003 to measure the strength to overcome threat and pressure (Connor & Davidson, 2003). There is a 10-item version of the Connor-Davidson questionnaire that was extracted from the 25-item questionnaire, and this study was used the 10-item questionnaire to measure resilience. To answer the questionnaire, the participants had to choose from the 5-point Likert scale (not correct at all (zero), rarely correct (1), sometimes correct (2), often correct (3) and completely correct (4)) and the range of scores was between 0 to 40. Finally, the total score earned by each individual determined his/her resilience, meaning that the higher the score the more the resilience (Seyedfatemi2 et al., 2019).
Many studies have confirmed the validity and reliability of this questionnaire (Campbell-Sills & Stein, 2007; Keyhani, Taghvaei, Rajabi, & Amirpour, 2015; Seyedfatemi2 et al., 2019). However, to ensure the reliability of the questionnaire, the researcher administered it to fifteen caregivers of clients who were not part of the research community. They had similar characteristics to this population, and via employing the internal consistency method, the calculated Cronbach's alpha coefficient for this questionnaire was 0.86, which indicates the optimal reliability for this tool.
After receiving the code of ethic (IR.MUK.REC.1398.15), Sampling was performed for two months. After explaining the objectives of the study, ensuring the confidentiality of information, and attracting the participation of caregivers, a written consent was taken from the participants. Besides, the researcher reminded the participants that there would be no obligation for them to participate in the research.
Because the selection of the control and experimental groups was done simultaneously from one medical center, first the control group and then the experimental group were examined, so that the data collection would not be biased. Both groups completed the demographic and resilience questionnaires in two intervals. The pre-test was administered at the beginning of the research and the post-test was administered immediately after the training.
The psychological training for the experimental group was performed for 4 weeks in a session of 45 to 60 minutes per week. The training sessions were held in groups of 4 to 5 participants, several times a week, according to the request and conditions of the caregiver via a group discussion and in a question-and-answer form. At the end of the intervention, the post-test was administered for the experimental group. There was no intervention in the control group; however, after giving the post-test to the experimental group, in order to comply with the ethical standards, the educational content that was provided for the experimental group was also presented to the control group.
The implementation of the psychological training program, the number of sessions, and the general framework of the educational content were as follows:
The first session started with the introduction of the researcher and the members of the group. Then, the researcher stated the purpose of the psychological training sessions for the caregivers. Next, the researcher asked each of them to give a brief explanation of the bipolar disorder to find out how much the caregivers have known of the disorder. The researcher, then, discussed the prevalence of the disease, common symptoms, underlying causes, its treatments, and the way to care for the client, and finally introduced some famous and successful people with bipolar disorder to the participants.
The second session started by reviewing the previous session and then the following question was asked from the caregivers; "How do you deal with stressful life situations such as aggression and irritability of the client under your care?" Then, each of the caregivers, expressing their experiences of dealing with the situation, discussed with each other. The researcher, getting acquainted with how the caregivers would deal with stressful and difficult living conditions, referred to the concept of resilience and asked them to express their views on the concept and ways to improve it. After summarizing the participants' opinions, the researcher finally explained the concept of resilience and the strategies to improve it for the participants of the meeting.
The third session began with a review of resilience and the strategies to improve it, outlined in the previous session, and then the following question was raised: "What methods or skills do you use to overcome problems in your life?" Then, they discussed life skills and their proper use in difficult living conditions in order to live better.
The fourth session was dedicated to reviewing the topics of the previous three sessions and the valuable comments and suggestions of caregivers in this regard.
The topics discussed in the psychological training sessions were presented in the form of a pamphlet in order to help resolving ambiguities for the caregivers, considering the discourse of question and answer throughout the sessions. Table 1 also briefly shows the number of sessions and the titles of the educational content for each session.
Table 1
psychoeducation program provided for 4 weeks
Training Sessions
|
Educational Content
|
Week 1
|
• Severe mental disorders, signs and symptoms
• Pharmacological and non-pharmacological treatments
• Caregiving related plans, and familiarity with the concept of care burden
|
Week 2
|
• Reducing care burden and increasing health by emphasizing on the ability of "self-awareness"
• Reducing care burden and increasing health by emphasizing on the ability of "problem solving"
|
Week 3
|
• Reducing care burden and increasing health by emphasizing on the ability of "stress management"
• Reducing care burden and increasing health by emphasizing on the ability of "anger control"
|
Week 4
|
• Reducing care burden and increasing health by emphasizing on the ability of "effective communication"
• Reducing care burden and increasing health by emphasizing on the ability of "positive thinking"
|
The data analysis was performed using descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (independent t-test, paired t-test and analysis of variance with repeated measures) using SPSS-22.