Solution-Focused Brief Approach for Caregiver of a Person Living with Schizophrenia: A Case Study

Abstract

Introduction: In Asian countries, about 70% of people with Schizophrenia live with their families or friends. Caregivers are the persons who have significant responsibility for the well-being of a person diagnosed with Schizophrenia. In developing countries, the joint family system and the sense of collectivism resist paid caregivers for a person with Schizophrenia. As a result, caregivers may experience psychological and emotional distress and have poor mental health.
Aim of the Study: To assess the caregiver's burden, Quality of life and coping patterns of caregiver's of persons living with Schizophrenia.
Materials and Methods: The researcher had used single case AB design pre- and post-assessment methods. The researcher administered Pai and Kapoor's Family Burden Interview Schedule, Brief Cope by Carver et al., and WHO Quality of Life-BREF. The scaling technique was used to assess the change in the post-assessment.
Results
The therapist took 10 sessions, each lasting for 45-60 minutes. The therapist organized the sessions into initial sessions, which included 2 sessions for building rapport, providing psychoeducation, developing a case conceptualization, and discussing the techniques that would be used. Additionally, there were 6 middle sessions focused on implementing core therapeutic techniques. After conducting psychoeducation sessions, utilizing the miracle questions, discussing preferred future outcomes, exploring exception questions, and implementing coping techniques with the mother, behavior management was taught to address the client's demanding behavior and emotional outbursts. Two sessions were dedicated to gathering feedback on the therapy process, preparing the mother for potential setbacks, and developing relapse prevention strategies.
Conclusion: At post-assessment, the caregiver reported amelioration in burden, coping pattern, and Quality of life. The mother learnt the management of the illness and was quite confident in handling the PLWS. The scaling question at the time of preassessment was 1, and at post-assessment was 7.

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J. Psychosoc. Rehabil. Ment. Health
https://doi.org/10.1007/s40737-024-00434-y
CASE DISCUSSION
Solution‑Focused Brief Approach forCaregiver ofaPerson
Living withSchizophrenia: ACase Study
AmitKumar·
JanakiRamanKalyanasundaram ·
JohnP.John· BinukumarBhaskarapillai
Received: 3 June 2024 / Accepted: 2 September 2024
© The Author(s), under exclusive licence to Springer Nature India Private Limited 2024
sessions, which included 2 sessions for building rap-
port, providing psychoeducation, developing a case
conceptualization, and discussing the techniques that
would be used. Additionally, there were 6 middle ses-
sions focused on implementing core therapeutic tech-
niques. After conducting psychoeducation sessions,
utilizing the miracle questions, discussing preferred
future outcomes, exploring exception questions, and
implementing coping techniques with the mother,
behavior management was taught to address the cli-
ent’s demanding behavior and emotional outbursts.
Two sessions were dedicated to gathering feedback
on the therapy process, preparing the mother for
potential setbacks, and developing relapse prevention
strategies. At post-assessment, the caregiver reported
amelioration in burden, coping pattern, and Quality
of life. The mother learnt the management of the ill-
ness and was quite confident in handling the PLWS.
The scaling question at the time of preassessment was
1, and at post-assessment was 7.
Keywords Schizophrenia· Solution-Focused Brief
Intervention· Caregiver Burden· Coping Pattern·
Quality of Life
Introduction
Schizophrenia is a chronic mental illness character-
ized by distortions in thinking, perception, emotions,
and behavior, with common symptoms including
Abstract In Asian countries, about 70% of people
with Schizophrenia live with their families or friends.
Caregivers are the persons who have significant
responsibility for the well-being of a person diag-
nosed with Schizophrenia. In developing countries,
the joint family system and the sense of collectivism
resist paid caregivers for a person with Schizophre-
nia. As a result, caregivers may experience psycho-
logical and emotional distress and have poor mental
health. Aim of the Study: To assess the caregiver’s
burden, Quality of life and coping patterns of car-
egiver’s of persons living with Schizophrenia. The
researcher had used single case AB design pre- and
postassessment methods. The researcher administered
Pai and Kapoor’s Family Burden Interview Sched-
ule, Brief Cope by Carver et al., and WHO Quality
of Life-BREF. The scaling technique was used to
assess the change in the post-assessment. The thera-
pist took 10 sessions, each lasting for 45–60 min-
utes. The therapist organized the sessions into initial
A.Kumar· J.R.Kalyanasundaram(*)
Department ofPsychiatric Social Work, National Institute
ofMental Health andNeuro Sciences, Bengaluru, India
e-mail: janakitrichy@gmail.com
J.P.John
Department ofPsychiatry, National Institute ofMental
Health andNeuro Sciences, Bengaluru, India
B.Bhaskarapillai
Department ofBiostatistics, National Institute ofMental
Health andNeuro Sciences, Bengaluru, India

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hallucinations and delusions (WHO, 2019). Affecting
approximately 20 million people worldwide, includ-
ing 0.4% of the Indian population, schizophrenia
places a significant burden on caregivers (Feigin etal.,
2019; National Mental Health Survey, 2015–2016).
The concept of "burden of care" emerged as families
assumed responsibility for patients after the closure
of mental hospitals, with this burden adversely affect-
ing caregivers’ general and mental health (Awad and
Voruganti, 2012; Schene etal., 1998).
Caregiver burden is divided into "objective bur-
den," which includes financial loss and disruptions to
daily life, and "subjective burden," which refers to the
personal perception of burden (Pai & Kapur, 1981).
In Asian countries, where about 70% of people with
schizophrenia live with family, caregivers face sig-
nificant challenges due to inadequate healthcare infra-
structure, leading to psychological distress, social
isolation, and poor physical and mental health (Chan,
2011; Opoku-Boateng etal., 2017; Ae-Ngibise etal.,
2015).
Research shows that caregivers often experience a
low quality of life (QoL), impacted by societal stigma,
education, health conditions, and coping strategies
(Opoku-Boateng etal., 2017; ZamZam etal., 2011).
Maladaptive coping strategies, such as denial, have
been linked to higher caregiver burden and adverse
outcomes for both caregivers and patients, including
increased relapses and reduced QoL (Pompeo etal.,
2016; Rexhaj etal., 2013; Grover etal., 2015). Ram-
mohan et al. (2002) found that caregivers who use
denial as a coping strategy significantly increase their
burden, often leading them to avoid family members
with mental illness and eventually abandon them to
psychiatric services. Addressing these challenges is
crucial to improving the well-being of caregivers of
persons living with schizophrenia.
Caregiver of a Person Living with Schizophrenia and
Solution-Focused Brief Intervention (SFBI)
Solution-Focused Brief Intervention (SFBI) is a
strengths-based, hope-driven approach adapted from
Solution-Focused Brief Therapy (SFBT), devel-
oped by Steve de Shazer and Insoo Kim Berg in the
1980s. Unlike traditional therapy, which often focuses
on problems, SFBI emphasizes building solutions
through questions about hope, preferred futures,
exceptions, coping, and scaling. Indian studies have
suggested the effectiveness of SFBT, with one study
specifically assessing its impact on family environ-
ments in schizophrenia care (Eakes etal., 1997).
SFBI is well-suited for mental health settings
because it is brief, typically achieving therapeu-
tic changes within three to five sessions (Franklin
et al., 2017), and flexible, as it can be administered
anywhere, including at the patient’s bedside (Burns
and Northcott, 2022). By enhancing the quality of
life and coping skills, SFBI helps address distress in
participants.
The Present Study
This study aimed to evaluate SFBI as a treatment
approach for caregiver of a person living with schiz-
ophrenia. The caregiver response to treatment was
assessed by their progress toward client-derived treat-
ment goals and improvement in overall caregiver
satisfaction over ten sessions of SFBI. Specifically,
the present study addressed the following research
questions.
Do 10 SFBI sessions reduce the burden, improve
coping patterns and the quality of life of the present-
ing concern of the caregiver of a person living with
schizophrenia?
Materials andMethods
The researcher used a single-case AB design with
pre- and post-assessment methods. The researcher
administered Pai and Kapoor’s Family Burden Inter-
view Schedule, Brief Cope by Carver etal., and WHO
Quality of Life-BREF (Group, 1998). The measure-
ments used in the study are well renowned and have
been used in many scientific studies.
A scaling question was used to evaluate changes
between pre-assessment and post-assessment. Ini-
tially, the mother was asked to rate her situation on a
scale from 1 to 10 and explain what that score meant
to her. The same process was repeated during the
post-assessment to gauge any changes.
Risk of Bias
We employed the third-person perspective to mini-
mize potential bias in our post-assessment analy-
sis. By referring to participants and their actions

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detachedly, we aimed to ensure that our assessment
remained impartial and that the results were not
unduly influenced by personal involvement or precon-
ceived notions.
Participant
Caregiver History
Mrs. S, a 53years old, mother, educated up to 5th
standard, is a homemaker. She has been caring for
the client since the start of the illness, which is
12years. Other family members support her in car-
ing for the client, but she mostly does all the work.
She gets good support from her elder daughter,
and the younger son helps her in some chores. She
hails from a semi-urban area of Bihar and spent her
whole life caring for household chores. The client
who is diagnosed with schizophrenia shows many
symptoms related to the illness, like delusions, hal-
lucinations, anger/emotional outbursts, etc., and the
mother and other family members become clue-
less about how to respond in that particular situ-
ation and end up in arguing with the client which
makes the situation even more worse. The other
family members include the Husband, who is retired
and receiving a pension; the elder daughter, who
is working as a chartered accountant; the younger
son, who is currently studying; and the client, who
has pursued B.Tech and is currently not working.
Their lack of knowledge and management of the
client prompted them to mental health intervention
(Table1).
Results
Scaling Question
The therapist used scaling questions in almost all
the sessions to find out the changes throughout
the session. The therapist asked a scaling question
in the first session: "On a scale of 1–10, where do
you think you are standing?" The mother responded
with 1(one). When the therapist asked the mother
the same question in the last session, she responded
7(seven). When asked what 7 meant to her, she
replied that she understood the treatment process,
had learned to manage the patient and the fluctua-
tions, and had learned to cope with the situations
(Table2).
Table 1 Solution-focused brief therapy session information
Solution-Focused Brief Intervention for Caregiver (Solution-Focused Therapy Treatment Manual for Working with Individuals 2nd
version (Bavelas etal., 2013)
Session Main intervention Caregiver response
1 Orientation about the Intervention Informed about the intervention, purpose of the meeting, and purpose of intervention
2 Preferred Future Questions Identified her preferred future and made her realize when the change started to happen
3 Psychoeducation Educated about the diagnosis of schizophrenia to make her understand the illness
4 Formula First Session Task The therapist gave the task of observing the changes that happened between this session
and the next
5 Goal-Setting Enhancing their skills to understand best hopes
To help them recognize the change happening by using miracle questions
6 Coping and Exception Questions Explored coping patterns of caregiver
Explored previous solutions for caregiver
Explored the exceptions in caregiver
7 Community Integration Explored the options to reunite the client in the client
Explored the rehabilitation options for the client
8 Relationship Question Explored the individual’s close relationships by asking who would be most likely to
notice any changes, which also helped identify their support system
9 Scaling Question Assessed the burden, coping, and quality of life in post-assessment to find out the
changes
10 Termination/Booster Reviewed the treatment and the progress that they have made over time

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Family Burden Interview Schedule (FBIS)
The caregiver completed this instrument’s pre- and
post-assessment, and the duration was four weeks. No
financial burden was found in the pre-assessment, but it
was a moderate burden on loss of income. In disruption
of routine family activities, the score was close to the
moderate burden, which came down at the end of the
session (S: 10 = 4–2). The disruption of family leisure
showed moderate to high came down at the end of the
session (S: 8 = 6–4). Disruption of family interaction
was also found to be disturbed, which was moderate
to severe. There were challenges related to communi-
cation among family members regarding how to deal
with the client’s anger/emotional outbursts. The family
members often feel clueless and do the same as the cli-
ent used to do, making the situation even more worse.
The mother reported improvement in communication
patterns during the session (S: 10 = 7–4). The family
members were affected physically and mentally due to
the illness of the client that the therapist addressed, and
the mother reported that she could feel less burdened
(Table3).
Brief Cope
This scale has three domains: (a) Emotion-Focused
Coping, (b) Problem-Focused Coping, and (c) Avoidant
Coping. In the pre-assessment, the scores of emotion-
focused (S: 48 = 18) and problem-focused (S: 32 = 12)
coping were low, and avoidant coping (S: 32 = 24) was
high, which indicates that the mother was using nega-
tive coping more compared to positive coping. The
therapist explored the mother’s previous successive
positive solutions and encouraged her to do that often
to deal with the problems. At the end of the session, the
mother reported positive ways to deal with the prob-
lems, and the scores for emotion-focused were (S: 30),
problem-focused (S: 19), and avoidant coping (S: 16)
(Table4).
Quality of Life
The quality of life impacted a lot during the pre-assess-
ment; the raw score for the domains of physical health
(S: 35 = 7), psychological (S: 30 = 8), social relationship
(S: 15 = 8), and environment (S: 40 = 13). The thera-
pist used preferred future and miracle questions, which
helped improve the quality of life. The post-assessment
scores for the domains were physical health (S: 10),
psychological (S: 13), social relationship (S: 10), and
environment (S: 16) (Table5).
Discussion
Our purpose in selecting this case study is to evaluate
SFBT as an appropriate family intervention approach
for the caregiver of a person living with schizophrenia.
Table 2 the pre- and post-assessments of the results of the
Scaling Question
Pre-assessment Post-assessment
Scaling question 1 (10%) 7 (70%)
Table 3 the pre- and post-
assessments of the results
of FBIS
Family Burden Interview Schedule (FBIS) Pre-assessment Post-assessment
Disruption of routine family activities 4 (40%) 2 (20%)
Disruption of family leisure 6 (75%) 4 (50%)
Disruption of family interaction 7 (70%) 4 (40%)
Table 4 The pre- and post-assessments of the results of Brief
Cope
Brief cope Pre-assessment Post-assessment
Emotion-focused coping 18 (37.5%) 30 (62.5%)
Problem-focused coping 12 (37.5%) 19 (59.37%)
Avoidant coping 24 (75%) 16 (50%)
Table 5 represents the pre- and post-assessments of the qual-
ity-of-life results
Quality of life Pre-assessment Post-assessment
Physical health 7 (20%) 10 (28.57%)
Psychological 8 (26.66%) 13 (43.33%)
Social relationship 8 (53.33%) 10 (66.66%)
Environment 13 (32.5%) 16 (40%)

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We were interested in whether the SF approach can
help the caregiver with the burden, coping pattern, and
quality of life. Family Intervention generally demon-
strates a significant, positive effect on burden, coping
patterns, and quality of life (Bahrami & Farzi, 2014;
Sari & Duman, 2022). As previously discussed, Car-
egivers with PLWS often experience the burden of care
for PLWS, may use maladaptive coping patterns, and
have a poor quality of life (Opoku-Boateng etal., 2017;
ZamZam etal., 2011; Grover et al., 2015) which may
interfering in dealing with PLWS.
An SF approach emphasizes the collaborative
and empowering role of the therapist when work-
ing with caregivers (Turns et al., 2019). It became
apparent that Mrs. S used expressed emotions to deal
with the situation, which was critical comments that
negatively affected PLWS’s distress related to his
emotional/anger outburst. The therapist used coping
and exception questions to explore ways Mrs. S effec-
tively dealt with the symptoms of PLWS (i.e., behav-
ioural problems) based on previous solutions instead
of expressed emotions, thereby addressing both car-
egiver and PLWS needs and continuing towards the
treatment goals.
Our findings successfully addressed our research
questions, suggesting that the SF approach may be
an effective clinical strategy to alleviate the caregiver
burden (i.e., symptoms) associated with caring for a
person living with schizophrenia (PLWS). The mother
in the study reported a reduction in burden across
nearly all domains, with the most significant improve-
ment observed in family interaction patterns. She
gained a deeper understanding of the illness, learnt
strategies to manage PLWS symptoms, and became
more aware of potential setbacks and future plans.
The therapist provided psychoeducation to address all
concerns related to the PLWS, which played a crucial
role in reducing the caregiver’s burden.
Additionally, the mother’s coping patterns showed
notable improvement in emotion-focused, problem-
focused, and avoidant strategies. Positive coping pat-
terns, such as emotion-focused and problem-focused
approaches, are associated with better behavior and
improved recovery outcomes, while negative cop-
ing patterns, like avoidance and expressed emotions,
can hinder illness outcomes (Devaramane et al.,
2011). Lastly, the mother’s quality of life, as it relates
to caring for a PLWS, showed enhancement in all
domains—physical health, psychological well-being,
social relationships, and environmental factors—after
ten therapy sessions. The studies proved that family
intervention programs can help improve the caregiv-
ers’ quality of life (Verma et al., 2019). However,
modifying the solution-focused therapeutic stance
may be appropriate by explicitly recommending
a treatment goal for caregivers of PLWS, such as
acceptance and social support, to improve quality of
life. These findings have important clinical implica-
tions for using the SF approach as a clinical approach
for caregivers of PLWS.
Limitations
An inherent limitation of the case study design is the
generalizability of the findings. The study’s findings
ought to be restricted to therapists working with het-
erosexual caregivers of people with schizophrenia.
Findings indicate that the other caregivers of PLWS
may go through different problems compared to only
one caregiver, and duration and symptoms of illness
can also play an essential role in the recovery of the
illness and can affect the mental health of the caregiv-
ers differently. Additionally, therapist bias, influenced
by personal beliefs or past experiences, could inad-
vertently shape the therapy’s direction, potentially
leading to confirmation bias or overlooking contra-
dictory evidence. This underscores the need for self-
reflection and supervision to preserve the objectivity
of the therapeutic process. Future research should
replicate the approach with various therapists to
account for potential therapist effects on the findings.
More than one caregiver can be assessed to under-
stand the problem in detail and prepare an effective
treatment.
Conclusion
As the Indian prevalence of persons living with
schizophrenia continues to rise, there is likely to be
a corresponding increase in caregivers who need
intervention related to their concerns. Because of
its strength-based focus and collaborative therapeu-
tic stance, the SF approach may acquire traction as
a suitable therapeutic approach to meeting the rela-
tional needs of PLWS caregivers. Despite its limited
generalizability, the findings of this study provide an
in-depth assessment of SF as a therapeutic option for

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caregivers of PLWS. Ongoing research is necessary
to explain these findings further and explore appro-
priate solution-focused modifications or integrations
that improve caregiver-related treatment outcomes of
PLWS.
Funding This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-
profit sectors.
Declarations
Conflict of interest None of the authors has any conflict of
interest.
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