Brief Mindfulness-Based Family Psychoeducation Intervention for Chinese Students With Early Psychosis: A Mixed Methods Study
Phase: NA
Conditions: Psychotic Disorder
Sponsor: The Hong Kong Polytechnic University

Cover page 
 
Official Title of the study: Brief Mindfulness-Based Family 
Psychoeducation Intervention for Chinese Students with Early 
Psychosis: A Mixed Methods Study 
 
NCT number (if available): NCT ID not yet assigned 
 
Date of the document: September 17, 2018 

1 
 
BACKGROUND RESEARCH 
Severe Mental Illness (SMI), Early psychosis (EP), and its impact on student’s development 
Serious Mental Illness (SMI), traditionally named psychosis, is defined as a mental, 
behavioural, or emotional disorder that has been medically diagnosed for at least one year. SMI 
usually results in serious functional impairment, which substantially interferes with, or limits 
one or more major life activities and functions in social, family, and vocational/educational 
contexts (Lefley, 2009). The number of adults with SMI represents 4.1 % of the population in 
United States (Center for Behavioral Health Statistics & Quality, 2015). In Hong Kong, the 
lifetime prevalence of SMI was 2.5% (Chang et al., in press). The term early psychosis (EP) is 
typically used for young people before and after their first identified episode. 
SMI has a marked increase in prevalence between ages 15 to 17. The majority of SMI 
manifests in the age group 20 to 30, with a median of age for first psychotic episode of 22 
(Kessler et al., 2007). Young people with SMI often have delimited social networks and 
experience much social isolation (Bebbington & Kuipers, 2008). A study reported at the first 
contact to EP service, over 40% of these young people were not in school or unemployed 
(Marwaha et al., 2004). A meta-analysis reported that 34.5% of the individuals with psychosis 
perpetrated violent behaviours before admission to psychiatric services (Large & Nielssen, 
2011). Recent studies in Hong Kong found that 42% of the patients with first episode psychosis 
reported suicidal ideation, and 9.4% committed violent behaviours (Chang et al., 2014; Chang 
et al., 2015). Students with EP experience a high-risk period and it causes many family 
caregivers under immense strain and anxiety. 
Family caregivers of young people with EP 
Family caregiving is defined as the behaviour of one’s commitment to the welfare of another 
family member, and the provision of voluntary care to meet their physical, psychological and 
developmental needs (Revenson et al., 2016). Family caregivers often take up their roles 
without any formal preparation, knowledge, resources or skills, and frequently experience 
many psychological burdens. Such burdens can be assessed in empirical terms, referring to the 
consequences on the family’s physical and psychological well-being due to these symptoms 
and behaviours. The management of family member’s bizarre behaviors, fluctuating emotions, 
suicidal ideations, and being unemployed after onset of EP became the major sources of 
caregiving burden (Wong et al., 2012). Burden can also be perceived in subjective terms, 
involving the appraisal of individual caregivers, relating to their difficult emotions arising from 
the suffering of the family member, such as loss, grief, and the negative perceptions from 
relatives and neighborhood (Lefley, 2009). Studies have shown that over one-third of the 
caregivers experienced emotional distress, such as depression (Chen et al., 2016). 
Some earlier studies of caregiving have focused on family expressed emotions (EEs), a robust 
predictor of relapses and overall outcome of SMI, including number of relapses, hospitalization, 
and symptom severity (Hooley, 2007; Weintraub et al., 2015). High EEs are defined as 
criticism, hostility, and over-involvement (Brown, Birley & Wing, 1972), and are considered 
as a reciprocal process in family interactions that are developed and increased after illness onset, 
particularly in the first five years (Hooley, 2007). Reduction of caregiving burden has been 
associated with an acceptance of the patient’s behaviours, illness course and caregiver’s own 
social functioning (Magliano et al., 2000). 
However, other studies of EEs targeted on EP have suggested a more complicated picture. A 
recent review of higher EE concluded that higher levels of criticism predicted positive 
symptoms of SMI, but no association was found in negative symptoms of EE, including 
criticism and emotional over-involvement (Cechnicki et al., 2012). Further, avoiding coping, 
negative appraisals of the impact of illness, and perceived losses were associated more 
frequently with family EE. This implies that mindfulness can promote more caregiver 
acceptance of their afflicted youth that in turn, will help to reduce EE and caregiver burden 
(Jansen, Gleeson, & Cotton, 2014). Among families facing EP, over-involvement is often a 
normal process, as young people have not fully developed their own self-care abilities, and the 
boundaries between positive concern and family over-involvement is blurred and unclear 
(McNab & Linszen, 2009). Higher level of EE was also more likely to be found in families 
from non-Western cultures, such as India, Japan, and China (Bhugra & McKenzie, 2010). It 
may be the cultural norm in these countries, as it co-exists with positive factors such as family 
connectedness and strong family ties. A study of African-American patients found that higher 

2 
 
level of EE has been associated with better overall outcomes, suggesting the association 
between EE and outcomes is less straight forward in non-Western cultural groups (Gurak & 
Mamani, 2017). 
Psychoeducation for family caregivers 
Family psychoeducation (FPE) is a core component in the treatment for SMI or EP, as 
recommended by The Schizophrenia Patient Outcomes Research Team (PORT) and National 
Institute for Health and Care Excellence (NICE) (Dixon et al., 2010; NICE, 2015). Many FPE 
programmes apply cognitive behavioural models with an emphasis on family dysfunction, 
characterized by high EEs, and usually involve the teaching of practical knowledge and skills 
required to manage EP (McFarlane, 2016, Sellwood et al., 2007). Other programme 
components include empathic understanding, social supports, normalization of reactions, 
resource information, exchange of coping strategies, and installation of hope (Lefley, 2009). 
The efficacy of FPE is still inconclusive. A meta-analysis reported FPE largely benefited 
patients and their one-year relapse rate reduced from 41 to 53% for the study control group, to 
6 to 12% for a treatment group. However, the improvements for caregivers were limited 
(Magliano & Fiorillo, 2007; Yesufu-Udechuku et al., 2015). Findings of FPE in Hong Kong 
studies are also mixed. A study of a FPE programme reported selected improvements in the 
functioning of patients and families, caregiving burden, and fewer relapses (Chien & Wong, 
2007). Another study reported improvements of patients and caregivers only at posttest. Effects 
at 1-year follow-up were sustained for caregivers, but not for patients (Chan et al., 2009). 
However, participants from a peer-led support group reported stronger improvements in 
functioning of both patients and caregivers, compared with FPE (Chien & Thompson, 2013). 
However, EEs and family factors were not studied as an outcome in these studies, and all FPE 
participants were mixed groups, rather than specifically caregivers of young people with EP. 
As a result, research gaps in FPE programmes warrant attention. To improve the effectiveness 
of FPE, first, the design of a FPE should be more theory-driven. The assumption about higher 
EEs and their role in preventing EP and SMI relapses in Western studies have faced challenges, 
as many high burden families have not showed higher EEs (Lefley, 2009). A recent review 
study concluded that it remains unclear how and why FPE works (Gracio, Goncalves-Pereira 
& Leff, 2016). Second, intervention for FPE should be simple, practical, effective and 
sustainable. Previous programme designs were relatively long and unstructured. Some studies 
examined a 48-session programme, which created difficulties for fidelity and implementation, 
and families were burdened to participate in such intensive programme (Glynn, 2012). 
Advance practice knowledge about how to enhance the caregiver’s role functioning is deemed 
to be useful. Third, developmental needs and cultural issues for EP in Chinese families should 
be included as a guiding and contributive theoretical model (McGorry, Allott & Kackson, 
2009). The management of young people with EP is beyond the comprehension of most 
families, and strengthening resilience for understanding, managing, and promoting positive 
caregiving experiences may be equally important, in addition to reduction to reducing caregiver 
burden (Jansen et al., 2014). 
Mindfulness-based intervention and its application in families 
Mindfulness-based interventions have been widely adopted as an evidence-based approach in 
supporting people with chronic medical conditions (Bohlmeijer et al., 2010). Kabat-Zinn (2013) 
defined mindfulness as paying attention non-judgmentally, to the present moment. Mindfulness 
can improve one’s attention, promote tolerance to unpleasant sensations, and feelings, and can 
facilitate cognitive changes. It can strengthen a participant’s stress coping, by the integration  
of programmed mindfulness exercises with combined illness specific psychoeducation (Kabat- 
Zinn, 2013; Segal, Teasdale & Williams, 2013). In mindfulness-based programmes, instructors 
provide guided training to mindfulness exercises, including body scan, stretching, and mindful 
sitting. An inquiry into participant needs is followed by an exploration of their personal 
experiences. New insights and understandings about the participants’ reactions to stress will be 
addressed. In contrast to most FPE programmes, instructors do not offer answers or solutions 
for problem-solving and participants learn to acknowledge and develop their own capabilities 
to deal with their life challenges (Segal, Williams, & Teasdale, 2013). 
Some studies have applied mindfulness-based interventions to parents or caregivers with 
positive outcomes, despite their weak research designs, heterogeneous participants, small 
sample sizes, and/or the lack of a control group. Bögels and colleagues (2014) recruited 86 

3 
 
parents of children with mixed psychiatric diagnoses for a non-randomized clinical trial of a 
mindfulness programme. In this study, improvements were found in mental health symptoms 
of both children and parents, and parental stress. Intervention for caregivers of children with 
developmental disabilities are growing, and positive changes in perceived stress and depressive 
symptoms of caregivers have also been found (e.g. Dykens et al., 2014). 
To the knowledge of PI, there is no published randomized controlled study on application of 
mindfulness specifically for caregivers of young people with EP around the world. Thus, more 
studies targets to apply mindfulness to Chinese families are recommended to assist this 
knowledge building endeavour. 
 
Hypotheses of the study 
Based on the literature, two hypotheses have been proposed for this study: i) caregivers who 
participate in a MBFPE will experience less perceived stress, less depressive symptoms, more 
positive caregiving experiences, higher levels of mindfulness, and higher level of non- 
attachment than participants in the FPE. ii) young people with EP will report less psychiatric 
symptoms, higher level of recovery, and lower EEs, after their caregivers’ participation in 
MBFPE, compared to the control group. 
 
RESEARCH PLAN AND METHODOLOGY 
Study design 
This study uses a mixed methods design embedded in a multi-site, randomized control trial. 
The effects of this intervention will be tested using a two-arm randomized controlled trial, 
comparing the MBFPE (Arm 1), to an ordinary FPE (Arm 2). Assessments will be made before 
(T1), and after intervention (T2), and at the 12-month follow-up (T3). The programme effects 
will be tested using both between-subject (comparison of the two arms) and within-subject 
(comparison of measures at T1, T2, and T3). 
Refinement of design from a pilot study. A pilot study was conducted in mid-2017. 36 
caregivers were recruited in a non-randomized controlled trial. Compared with caregivers who 
received standard care, participants from MBFPE showed significant or marginally significant 
more improvements in caregiver perceived strain, (F[34] = 2.72, p = .11), compassion for the 
child (one component in interpersonal mindfulness) (F[34]=4.56, p <.05), positive caregiving 
experience (F[34] = 3.56, p = .07), and non-attachment (F[34]=3.41, p = .07). Follow-up 
meetings with social workers from a collaborating NGO, and feedback collected from 
participants were used to refine the MBFPE content and the mixed method design. 
Sample size estimation. Since no similar study of the same kind has been conducted, the sample 
size calculation is based on a study of a mindfulness-based intervention for parents of 
developmental disabilities, in which an effect size of 0.65 in stress (Lo, Chan et al., in press), 
with an estimation of an effect size of 0.15 for Arm 2. For a two-tailed α error of 5%, an 80% 
power, and a test of two independent groups, the required sample size will be 128 participants 
for two arms (Cohen, 1988). We further adjust the sample size based on an estimation of drop- 
out rate and intra-class correlation. An estimation of a drop-out rate of 15% is based on two 
local studies of mindfulness-based intervention (Hou et al., 2014; Lo et al., 2015). Besides, an 
estimation of intra-class correlations of 0.07 is based on PI’s two recent mindfulness multi-site 
studies ranged from 0 to 0.07 and related studies in Western studies (Adams et al., 2004; Lo et 
al., in press; Lo et al., under review), and 300 caregivers will be recruited for this study. 
Recruitment of participants. The study is based on convenient sampling, as it is not possible to 
collect a full list of young people with EP and caregivers in Hong Kong due to respect of 
confidentiality of medical records and personal data. Inclusion criteria are: 1) caregivers of a 
youth under the age of 30 who has been in Hong Kong secondary school or tertiary education, 
and who has experienced EP, or has a diagnosis of SMI, in the last three years. 2) caregivers 
who have offered the care to the student for at least one year. Exclusion criteria are: 1) 
caregivers who have diagnoses of SMI or developmental disabilities, such as intellectual 
disabilities, which may present difficulties in comprehending the content of the programme. 2) 
both caregivers and youth who refuse to receive regular psychiatric consultation. The research 
project will be announced and promoted in all psychiatric units of the Hospital Authority, 
psychiatrists in private practice, local school social work and youth mental health services, and 
student counseling services in all tertiary education institutions through emails, and postage of 

4 
 
project leaflets. Six NGOs have indicated their intentions to participate in this study by assisting 
in promotion, recruitment, programme implementation and data collection. Support letters of 
these NGO collaborators have been provided in the appendix. As a whole, all collaborators are 
accounted for the operation of 30% of the Integrated Community Centres for Mental Wellness, 
and 20% of the school social work service in Hong Kong. Their involvement in project 
promotion and recruitment can increase the number of caregivers to participate in this project. 
Based on a recent study, the number of youth meeting the criteria of EP was about 600 per year 
(Tang et al., 2010), the target of sample size will be met if one of eight caregivers of EP apply 
for the study programme. All interested caregivers will be invited to participate a briefing 
session, to explain the rationale and procedures of the study. Social workers from the NGO 
collaborators will provide standard care to the selected youth, and encourage them to participate 
the study. However, they will not be involved in data collection and will be fully blinded to the 
randomization process. A research assistant also blinded to the personal data of the   
participants,   will   administer   the   random   assignment   using   computer    generated 
programming. Participants will be randomly assigned to MBFPE (Arm 1), or ordinary FPE 
(Arm 2). At the same time, both arms are called “Family Psychoeducation Programme”, and 
the term “mindfulness” will not be used for Arm 1 to minimize the potential placebo effect. 
Cash remuneration coupons will be provided to caregivers and youth with EP who can 
complete the study at T2 and T3. 
Procedures 
Programme planning and training. The themes and content of arms 1 and 2 are summarized in 
Appendix 1. There are based on best practices in family work for SMI (Froggatt et al., 2007; 
McNab & Linszen, 2009). Both programmes include understanding EP, medication, treatment 
management, mental health service collaboration, attention to caregiver’s experiences and 
distress, strategies for improving communication and problem-solving, and crisis planning. An 
internal grant has been approved for producing a video that covers above key topics, and a 
teacher in psychiatric nursing and senior occupational therapist will assist PI in designing the 
video. The video shows will be supplemented by discussion with participants. Protocols have 
developed, and have been refined based on the feedback from instructors, participants, and 
NGO social workers in pilot study. Instructors for Arm 1 require basic professional training in 
mindfulness-based intervention, plus at least two-year experiences in conducting mindfulness- 
based programmes. Instructors for Arm 2 will be recruited from NGO with experiences in 
working with caregivers for more than two years. 
Implementation and assessment. After the first assessment (T1), caregivers who meet inclusion 
criteria will be randomized into a MBFPE (Arm 1) or an ordinary FPE (Arm 2). After the 
intervention, participants in both arms will complete the second assessment of the study (T2). 
For Arm 1, one-hour mindfulness training is infused with one-hour psychoeducation. For Arm 
2, the entire session is reserved for information given, problem-solving and mutual support. 
Both arms involve six sessions, with a total contact time of 12 hours. Both programmes include 
ten-minute daily homework practice, with Arm 1 being guided with mindfulness exercises, and 
Arm 2 with stress management talks. Both arms are delivered in group format, with 12 to 18 
caregivers in each group. Programmes will be conducted in the service units of NGO 
collaborators at Wanchai, Wong Tai Sin, and Tsim Sha Tsui, and other convenient locations 
for participants. A 9-month follow up (T3) is offered as a booster and final assessment for arms 
1 and 2. To ensure intervention fidelity, all programme sessions will be audio-recorded and an 
independent rater will listen to 20% of the selected clips on random basis, and assess whether 
each element in the intervention protocol has been implemented with consistency. Higher 
concordance rates will signify greater fidelity to the intervention protocol, which will be 
carefully monitored throughout the study. The treatment fidelity of Arm 1 will be further 
assessed by Mindfulness-based Interventions-Teaching Assessment Criteria Scale (Crane et al., 
2013). 
Embedded mixed methods design. The embedded mixed methods design used examines 
programme outcomes through experimental design, explore the process of the intervention 
through qualitative study method Photovoice. Based on the previous literature review, there 
are some queries about the overall caregiving process, and its effects to recovery of student 
with EF. The quantitative data will be used to investigate the ‘outcomes’ of the MBFPE, and 
to test if MBFPE can attain positive changes for family caregivers and the youth with EP. A 

5 
 
supplementary, qualitative, participatory action research (PAR) method called Photovoice, will 
be adopted to engage participants to contribute to the more candid and in-depth knowledge of 
the caregiving process, and to explore the ‘processes’ occurring during MBFPE and the follow- 
up period (Wang, 1999). In the qualitative study, caregivers will contribute to offering a unique 
contextual understanding of the outcomes, and for discovering ideas, insights, suggestions, 
questions, and outcomes that have not been adequately addressed by previous literature. This 
also offsets the threats of internal validity of the intervention (Bryman, 2006). 
Photovoice, as qualitative method technique, can facilitate people to record and reflect about 
their strengths and concerns of being a caregiver, to foster dialogue about caregiving process 
and personal experiences in MBPFE, by sharing ideas and discussions of their photos (Ho, 
Rochelle & Yuen, 2011; Wang, 1999). These procedures include: 1) in MBFPE sessions 2 to 
5, themes of Photovoice are included as homework assignments; 2) guidelines will be offered 
at the end of the sessions and participants will be encouraged to take pictures using their 
smartphones; 3) participants can write down their reflections on the images and share them in 
the following sessions, and send their pictures and reflections to the research team; 4) in the 
subsequent session, a time for collaborative enquiry on the pictures and reflections is included. 
With the consent of the participants, pictures, reflections, content of the in-session enquiries 
will be displayed. All participants will be involved so as to share and comment on the pictures 
and reflections about both mindfulness and caregiving. 5) At T3, all pictures will be re- 
displayed and participants will be invited to view their pictures, to share additional reflections 
about their experience of caregiving and participation in MBFPE, and highlight their reflections 
about MBPFE and caregiving from their own experiences. 
An Ethical approval for this study has been obtained from the Research Office of the Hong 
Kong Polytechnic University (ref: HSEARS20161122002). 
Measures 
All measures of the variables are summarized in Table 1 below. In line with the study objectives 
and hypotheses, primary outcome variables include caregiver stress, and student psychiatric 
symptoms. Secondary outcome measures include caregiver’s experiences, depressive 
symptoms, overall well-being, interpersonal mindfulness, family functioning, and non- 
attachment for the caregivers, level of recovery of the students with EP, their perceived family 
EE, and behavioural indicators will be assessed. 
 
Table 1. Outcome variables and measures 
Study variables and measures 
Sources of 
data 
Validation in 
HK samples 
Primary outcome variables 
Caregiver’s general stress level 
- Measured by Zarit Burden Interview (ZBI) (22 items) (Zarit, 
Reever & Bach-Peterson, 1980).  
The total score ranges from 0 (low burden) to 88 (high burden).  
caregivers 
α   =   0.84 
(Tang et al., 
2016) 
Secondary outcome variables 
Caregiving experiences 
- Measured by Experience of Caregiving Inventory (Szmukler 
et al., 1996), with selected subscales of stigma (5 items), 
effects on the family (7 items), positive experience in 
caregiving (14 items).  
The Stigma score ranges from 0 (little experience of stigma) to 
20 (much experience of stigma). The Effects on the Family 
score ranges from 0 (little negative effects on the family) to 28 
(much negative effects on the family). The Positive Experience 
in Caregiving score ranges from 0 (little positive experience in 
caregiving) to 56 (much positive experience in caregiving). 
caregivers 
α   =   0.74 to 
0.91 (Lau & 
Pang, 2007) 

6 
 
Caregiver’s physical health and mental health 
- physical health measured by 14 item, physical distress 
subscale in Body-Mind-Spirit Well-Being Inventory (Ng et al., 
2005); anxiety and depression measured by Hospital Anxiety 
and Depression Scale (Zigmond & Snaith, 1983).  
The Physical Distress score ranges from 0 (low distress) to 140 
(high distress). The Anxiety score ranges from 0 (low anxiety) 
to 21 (high anxiety). The Depression score ranges from 0 (low 
depression) to 21 (high depression).  
caregivers 
α  =  0.87 (Ng 
et al., 2005) 
α   =   0.77 to 
0.82 (Leung 
et al., 1999) 
Caregiver’s well-being 
- measured by WHO-5 Well-Being  Index (Johansen, 1998).  
The total score ranges from 0 (bad well-being) to 25 (good 
well-being). 
caregivers 
α 
= 
0.86 
(Kong et al., 
2016) 
Caregiver’s perceived family functioning 
- Measured by 5 item, Family APGAR Scale (Smilkstein, 
Ashworth, & Montano, 1982), with five subscales in 
adaptation, partnership, growth, affection, and resolve.  
The total score ranges from 0 (dissatisfaction) to 10 (good 
satisfaction). 
caregivers 
α = 0.94 
(Nan et al., 
2013) 
Youth’s recovery 
- Measured by Mental Health Recovery Measure (Young & 
Bullock, 2005), with 30 items in eight subscales relating to 
positive dimensions in recovery including Overcoming 
Stuckness (OS; 4 items), Self-Empowerment (SE; 4 items), 
Learning and Self-Redefinition (LSR; 4 items), Basic 
Functioning (BF; 4 items), Overall Well-Being (OWB; 4 
items), New Potentials (NP; 4 items), Advocacy/Enrichment 
(A/E; 4 items) and Spirituality (2 items).  
The total score ranges from 0 (bad recovery-related 
experiences) to 120 (good recovery-related experiences). OS, 
SE, LSR, BF, OWB, NP and A/E range from 0 (bad recovery-
related 
experiences) 
to 
16 
(good 
recovery-related 
experiences). Spirituality ranges from 0 (bad recovery-related 
experiences) to 8 (good recovery-related experiences). Eight 
subscale scores are summed to compute a total score. 
students 
α = 0.96 
(Ye et al., 
2013) 
Caregiver’s interpersonal mindfulness 
- measured by the Interpersonal mindfulness in Parenting 
Scale (Duncan, 2007), with 23 items in four factors in 
Compassion for Child (CC), Emotional Awareness in 
Parenting (EAP), Nonjudgmental Acceptance in Parenting 
(NAP) and Listening with Full Awareness (LFA) (Lo et al., 
2018). 
The total score ranges from 23 (low mindfulness) to 115 (high 
mindfulness). CC ranges from 7 (low compassion for child) to 
35 (high compassion for child). EAP ranges from 6 (low 
emotional awareness in parenting) to 30 (high emotional 
awareness in parenting). NAP ranges from 6 (low 
nonjudgmental acceptance in parenting) to 30 (high 
nonjudgmental acceptance in parenting). LFA ranges from 4 
(less likely listening with full awareness) to 20 (more likely 
listening with full awareness). Four subscale scores are 
summed to compute a total score.  
caregivers 
α   =   0.70 to 
0.84 (Lo et 
al., 2018) 

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Caregiver’s non-attachment 
- Measured by short form (8 item) of Non-attachment    Scale 
(Sahdra, Shaver & Brown, 2010).  
The total score ranges from 8 (low level of nonattachment) to 
48 (high level of nonattachment). 
caregivers 
α 
= 
0.90 
(Mak, under 
review) 
Youth’s family expressed emotions 
- Measured by 12 item Level of Expressed Emotion Scale (Cole 
& Kazarian, 1988), with subscales in Criticism (4 items), 
Hostility (4 items) and Over-Involvement (4 items).  
Criticism, Hostility and Over-Involvement scores range from 
4 (low perceived expressed emotions from particular sources) 
to 16 (high perceived expressed emotions from particular 
sources). Three subscale scores are summed to compute a total 
score. 
students 
α = 0.75 to 
0.77 
(Ng & Sun, 
2011) 
Youth’s psychiatric symptoms 
- Assessed  by  the  Positive  and  Negative  Syndrome  Scale 
(PNSS) (Kay, Flszbein & Opler, 1988).  
Positive Scale ranges from 7 (few positive syndromes) to 49 
(many positive syndromes). Negative Scale ranges from 7 (few 
negative syndromes) to 49 (many negative syndromes). General 
Psychopathology Scale ranges from 16 (few general 
psychopathological symptoms) to 112 (many). 
- An independent research assistant who has at least 3–year 
related practice experience will score on positive and negative 
symptoms, and general psychopathology.  
students 
α = 0.73 to 
0.83 
(Chen et al., 
2005) 
 
Data Analyses 
Quantative data analyses: Baseline equivalence. The values of the selected primary outcome 
measures (PSS and PCSS) at T1, will be compared among participants in the two trial arms. 
The outcomes at T1 and the treatment-condition variable will be used as the dependent 
variables. Intervention effects. All analyses will be carried out according to the intention-to- 
treat approach. Missing values of participants will be imputed using the last-observation- 
carried-forward method (Moher et al., 2010). MANOVA will be used to evaluate the effects of 
the MBFPE (Arm 1), relative to FPE (Arm 2), and the analyses of the primary and secondary 
outcome measures, including PSS, PCSS, PNSS, and secondary outcome measures will be 
analyzed. In addition to the immediate programme effects, outcomes measured at T2 and T3 
will be compared, to assess whether maintenance effects will be sustained at 12-months. 
Qualitative data analyses: The PI and the research team will use grounded theory to analyse 
the Photovoice images, participant’s reflections, and MBFPE transcripts (Padgett, 2008). 
Conceptual categories arise through interpretations of data. The process described encourages 
the research team to be reflexive about the prior interpretive frames, interests and research 
context, relationships with participants, and modes of generating and recording empirical 
materials in the process of analyses (Charmaz, 2006). The team will watch the videotapes of 
the MBFPE sessions, and study transcripts of themes, categories, and concepts that are 
generated in inquires of Photovoice. The research team will share these reflections to the 
MBFPE instructors, and invite participants to clarify, elaborate, and critique the interpretations 
at T3. The simultaneous data collection, construction, and analyses involve constant 
comparative techniques, by coding the first MBFPE session, then coding the second session, 
then comparing the coding of these two sessions, then continuing the adding or altering the 
coding throughout the study. Theoretical sampling will also be undertaken to fill in gaps in the 
analyses (Belgrave, 2014). 
Collaboration with community stakeholders and the democratization of knowledge 
construction are the strategies for enhancing research credibility for PAR (Balazs & Morello- 
Frosch, 2013). Data analyses include collaborations with participants, social workers from the 
NGO collaborators, MBFPE instructors, and the research team. Social workers from the 
collaborating NGOs have been involved with the team since the pilot study for the formulation 

8 
 
of Photovoice procedure. Based on participant’s selected pictures, they contribute to the study 
by sharing their personal reflections in MBFPE. During this process, the most salient features 
of these dialogues will be jointly determined by the instructor, and MBFPE participants. 
Transcripts will be recorded and themes will be identified by the researchers. At T3, all pictures 
and the preliminary analysis will be deliberated with all participants, and concurrence on the 
coding and interpretations will be reached between researchers and participants. Participants 
can then comment on the findings of the analyses. Further meetings of research team members, 
and additional sharing sessions of Photovoice for mental health professionals help to strengthen 
the trustworthiness of the qualitative study findings and culminate the data analysis process. 

Project schedule (36 months) 
2019 
2020 
2021 
 
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 
Literature 
review 
Revision of 
protocol 
MBFPE/FPE Group 1 and 2 
Recruitment 
& pretest 
Intervention 
Posttest 
Follow-up 
MBFPE/FPE Group 3 and 4 
Recruitment 
& pretest 
Intervention 
Posttest 
Follow-up 
MBFPE/FPE Group 5 and 6 
Recruitment 
& pretest 
Intervention 
Posttest 
Follow-up 
MBFPE/FPE Group 7 and 8 
Recruitment 
& pretest 
Intervention 
Posttest 
Follow-up 
Data analysis 
Report writing 

 
Appendix 1.   Proposed Intervention program outline 
 
 
Content of Mindfulness-Based Family Psychoeducation (MBFPE) (Arm 1) and Family Psychoeducation (FPE) (Arm 2) 
 
Session themes 
Mindfulness-Based Family Psycho-Education 
(MBFBE)  (Arm 1) 
Family Psycho-Education (FPE)  (Arm 2) 
 
 
Core Process 
Non-judgmental, Collaborative inquiry, Self-Care 
Information giving, Problem-solving, Mutual support 
 
1. Working with 
Caregiving Stress 
 
 
 
 
2. The Struggles of 
a Caregiver 
 
 
 
 
 
 
3. The Struggles of 
a Person in 
Recovery 
a. Orientation to the program 
b. Mindfulness Practice: Mindful eating, Body scan 
c. Discussing the Effects of Caregiver Burden 
d.       Home       practice:       Body       Scan 
a. Mindfulness Practice: Mindful Stretching 
b. Inquiry on Practices 
c. Video show: Challenges in Caregiving and Self- 
Care 
d. Home practice: Mindful stretching and Photovoice 
(A Pleasant Moment) 
a. Mindfulness Practices: Mindful Sitting, Mindful 
Walking 
b. Inquiry on Practices & Photovoice 
c. Video show: Sharing of Persons in Recovery 
a. Orientation to the program 
b. Awareness of stress symptoms, Understanding 
stress and reactivity in caregiving 
c. Discussing the Effects of Caregiver Burden 
 
a. Discussion on Stress, Appraisal and Coping of 
Caregiving 
b. Video show: Challenges in Caregiving and Self- 
Care 
c. Discussion on Preventing Compassion Fatigue 
 
 
a. Psychoeducation on Strategies in Working with 
Positive & Negative Symptoms 
 
 
b. Video show: Sharing of Persons in Recovery 
c. Discussion on Strategies for Symptom Management 
and Promoting Recovery 
 
 
d. Home practice: Mindful Sitting, Three Minute 
Breathing, & Photovoice (An Unpleasant Moment) 

 
 
4. The Path of 
Recovery 
 
 
 
 
 
 
 
 
5. A Supportive 
Caregiving 
 
 
 
 
 
 
 
6. Review of 
Learning 
a. Mindfulness Practice: Working with Difficult 
Moments Using Mindfulness 
b. Inquiry on Practices & Photovoice 
c. Video Show by Psychiatric Nurse & Social 
Worker: Improve the Effects of Drug Treatment & 
Multi-Disciplinary Rehabilitation Services 
 
 
 
a. Mindfulness Practice: Be-friending Exercise, 
Mindful Communication 
b. Inquiry on Homework Practice & Photovoice 
c. Identifying Early Signs of Relapses and Crisis 
Management 
c. Home practice: Be-friending & Photovoice 
(Family & Care) 
a. Review on Mindfulness Practice: Body Scan, 
Mindful Sitting, & Befriending 
b. Inquiry on Photovoice 
c. Review of programme and personal learning 
a. Psychoeducation of Recovery Model and Multi- 
Disciplinary Collaboration 
 
 
b. Video Show by Psychiatric Nurse & Social Worker: 
Improve the Effects of Drug Treatment & Use of 
Multi-Disciplinary Rehabilitation Services 
c. Discussion on Improving Communication with 
  
People in Recovery and Mental Health Professionals 
a. Understanding Communication Skills in 
Caregiving: Skills Training & Role Plays   
 
 
b. Identifying Early Signs of Relapses and Crises 
Management 
c. Understanding Helpful Community Resources 
 
 
 
 
Review of programme and personal learning 
 
 
9-month booster 
Review of changes and benefits in mindfulness 
Inquiry on Photovoice 
Review of changes and benefits of the programme 
 
 
Note: Grey content indicates those areas are unique in specific program 
d. Home Practice: Working with Difficult Moments 
Using Mindfulness, & Photovoice (Recovery) 

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