A Review of Psychoeducation for Patients with

Cynthia C. Bisbee, PhD; and Garry M. Vickar, MD, FRCPC, DLFAPA

sychoeducation for schizophrenia right, some of these influences have re- During the past 2 decades, a flood of and other serious mental illnesses emerged in different forms to augment health-oriented messages have received Phas grown in prevalence during the basic psychoeducation. mass exposure. These messages deal pri- past 4 decades as more evidence accrues marily with heart disease, diabetes, hy- regarding its benefits for both patients HEALTH EDUCATION pertension, cancer, prenatal care, nutri- and families. A variety of influences have Psychoeducation is rooted in a variety tion, and exercise. A subspecialty within come together to produce what we know of historical approaches and is closely the field of psychology, “health psy- today as psychoeducation. Further, once related to newer theoretical approaches. chology” has emerged to deal with the psychiatric patient education/psycho- education became established in its own

Cynthia C. Bisbee, PhD, is Executive Director, The Wellness Coalition, Montgomery, AL; and President, C.C. Bisbee & Associates, LLC. Garry M. Vickar, MD, FRCPC, DLFAPA, is Medical Di- rector, STEPS, Christian Hospital NE, St. Louis, MO; Clinical Instructor, Department of Psy- chiatry, Washington University, St. Louis, MO; and Professor and Chairman, Department of Psychiatry, St. Matthews University, Grand Cayman, British West Indies. Address correspondence to: Cyn- thia C. Bisbee, PhD, The Wellness Coali- tion, 3060 Mobile Highway, Montgom- ery, AL 36108; fax: 334-293-6484; email: [email protected]. Disclosure: The authors have disclosed no relevant financial relationships. doi: 10.3928/00485713-20120606-03 © iStockphoto.com

Healio.com The new online home of PSYCHIATRIC ANNALS 42:6 | June 2012 Healio.com/Psychiatry | 205 maintenance of healthful lifestyles and in consultation, he was very short and GROUP THERAPY AND OTHER prevention of physical disease through clear; and it was not until the relations APPROACHES psychological interventions. or friends of the patient were admitted, Group therapy is a multifaceted ap- Psychological health has been ad- and he proceeded to communicate to proach to psychoeducation, with a va- dressed through the advocacy of stress them the result of the consultation, that riety of theoretical orientations. Groups management, moderation in alcohol and he appeared to full advantage. He then are offered based on transactional anal- drug use, and wellness. Serious mental gave a short practical lecture, not merely ysis, reality therapy, client-centered illness has not been a common subject on the symptoms of the patient, but on therapy, gestalt therapy, and many other of health education; however, related the disease generally, in which all that theoretical approaches. This variegated health problems such as alcoholism and was known on the subject was brought to collection got its start partly from Jo- depression have been represented in bear on the individual case, and in doing seph Pratt, MD, of Worcester, MA. Dr. these approaches. Many hospitals pro- this, his utterance was so deliberate, that Pratt began conducting patient educa- vide community education programs on it was easy to follow him. His explana- tion classes for his tuberculosis patients general health issues and are gradually tions were so concise that they always in 1905. From this beginning, support incorporating psychiatric illnesses into excited attention, and never tired; and groups developed to discuss the patients’ these presentations. the simplicity of the language in which problems and fears.6 A growing number of psychoedu- they were conveyed, where all technical Psychiatric or psychological indi- cational programs now include mental terms were studiously avoided, rendered vidual and group therapy has always health education interventions as data them perfectly intelligible. included a certain amount of teaching, continue to show the association between Many hospitals, clinics, and physi- even if not clearly identified and done medications for schizophrenia (particu- cian offices offer diabetes education, on a systematic basis. In conducting larly atypical antipsychotics), obesity, employing a complex series of classes with a patient who has a and metabolic disorders. Chronic dis- and individual instruction. For example, major psychiatric disorder, the therapist ease self-management programs, such patients can often learn good dietary must usually do a great deal of explain- as Stanford University’s Living Well,1 habits by manipulating plastic food ing to the patient about the illness and or the Solutions for Wellness2 series de- models to construct meals with the prop- about ways of coping. It is this effort on veloped by Lilly USA, have proven very er amounts of nutrients and calories. the part of therapists that has contributed valuable in addressing the overall health Coronary disease is also rapidly becom- to the development of patient education issues of patients with schizophrenia. ing a widely taught illness, with numer- for psychiatric patients. Many therapists ous books, films, videotapes, computer are conducting patient education with- PATIENT EDUCATION IN applications, home monitoring systems, out calling it that, and finding that the MEDICAL DISEASE and other patient and family education therapy itself is more efficient when the Patient education has become a rec- programs being offered. patient has this education. ognized necessity in medical care and is Patient education appears to improve Recent trends in psychotherapy with commonplace, particularly in the treat- patient understanding of illness; reduce severely disturbed patients, especially ment of chronic diseases such as diabetes delay in seeking treatment; and improve those with schizophrenia, have been to- and heart disease. A description of one patient adherence to prescribed treat- ward more structured approaches. Some of the earliest applications of this method ment regimens. Patient education has of these patients may be withdrawn, was recorded by McMichael in his 1968 become recognized as a core component dependent, and paranoid, have a low account of the work of Matthew Baillie, of nursing practice and as an expected frustration tolerance, and show reduced MD, of the Royal College of Physicians part of their daily role.4 thinking abilities. These cognitive defi- in London in the late 1700s.3 He de- Education plays a large role in the cits may make them unable to benefit scribed Dr. Baillie thus: emerging field of chronic disease care from traditional dynamic therapy ap- In examining a patient, for the purpose coordination sometimes referred to as proaches because of their inability to of learning the symptoms of the com- care transitions. Programs with a sub- process the level of ambiguity and sym- plaint, the questions he put were so stantial educational component have bolism. few as to give an impression of haste emerged to support patients and fami- Some patients with schizophrenia and carelessness; in conversing on the lies, and to increase skills among health may have neurological impairments7 case with the physician whom he met care providers.5 that make it impossible for them to

206 | Healio.com/Psychiatry Healio.com The new online home of PSYCHIATRIC ANNALS 42:6 | June 2012 attend to, concentrate on, comprehend, education has been rather limited. While PATIENT EDUCATION IN and retain the complexities of traditional these endeavors have been only loosely PSYCHIATRY insight-oriented psychotherapy. These associated, the techniques of behavioral Psychoeducation for schizophrenia patients need a supportive therapeutic medicine are quite appropriate if one – sometimes known as psychiatric pa- approach that is designed to reduce the considers serious mental illness to be a tient education – has gradually evolved level of stress in therapy, and a struc- physical condition. since the mid-1970s. Some of the earli- tured approach that makes the therapeu- Some of the techniques used in be- est efforts in this area took the form of tic environment less ambiguous. havioral medicine can be applied when medication classes or groups in inpa- Psychoeducation has grown to fit this designing psychiatric patient education tient psychiatric units, partial hospital- bill nicely. The same trend holds true in philosophies and methods. Typical ap- ization programs, or community mental working with families of persons with health centers. The nursing literature is serious mental illness, in that an edu- a source of numerous articles describing cational approach is often more helpful this kind of program.13-16 and more acceptable than an attempt at A program targeted specifically for therapy with a family who simply wants patients with drug-refractory unipolar support and knowledge about the illness, depression used a CBT psychoeduca- its management, and how to cope.8 tional group as treatment for depressed patients who had not responded to an- DIDACTIC PROGRAMS tidepressant medications.17 Another pro- AND SKILLS TRAINING gram focused on depression and used Many hospitals and treatment facili- the Coping with Depression Course for ties have been conducting some type of the treatment of patients with unipolar didactic therapeutic programs, which depression.18 concentrate primarily on the develop- Both of these programs de-empha- ment of social skills and others needed sized the role of biological treatment to live successfully in a community set- These behavioral medicine and focused on treating depression us- ting. A major example of this approach techniques are, therefore, ing a CBT approach. The Community is Liberman’s early development of pro- Interaction Program was established to grammed modules for community living applicable to serious integrate a psychoeducational approach skill training.9 mental illnesses. into various aspects of community treat- These programs consist of patient ment, including teaching about medi- workbooks, facilitator manuals, and cation, transitional employment, adult various media on medication manage- plications of these behavioral medicine basic education, and other aspects of a ment, symptom management, leisure techniques are the use of cognitive re- comprehensive social rehabilitation pro- skills, and other areas pertinent to cop- structuring, relaxation, systematic de- gram.19 ing with serious mental illness in the sensitization, and biofeedback. These Ascher-Svanum described a program community. The psychiatric rehabilita- behavioral medicine techniques are, of psychoeducational groups targeting tion approach10 also utilizes some di- therefore, applicable to serious mental inpatients with schizophrenia and has dactic methods, but does not emphasize illnesses in the same way that they are developed a manual for therapists’ use education about illnesses, working in- applicable to medical illness, once one in conducting these groups.20,21 Laffal, stead toward recovery of roles in living, accepts the premise that schizophrenia, Brown, Pearlman, and Burns established learning, and working. for example, is a medical disorder. a classroom course for psychiatric inpa- Most recent has been the emergence tients at the Connecticut Valley Hospi- BEHAVIORAL MEDICINE of cognitive-behavior therapy (CBT) for tal. The course consisted of 16 sessions Behavioral medicine is the appli- schizophrenia, which differs from psy- conducted over a 4-week period, which cation of behavioral techniques in the choeducation in that it focuses more on included patient workbooks and an in- treatment of physical illness.11 As a rela- symptoms rather than diagnosis, but has structor’s manual.22 McCrary has de- tively young field, its influence in the as one of its aims to help the patient ac- veloped a Patient and Family Education area of psychiatric patient and family cept and participate in treatment.12 Center (see following) patterned after

Healio.com The new online home of PSYCHIATRIC ANNALS 42:6 | June 2012 Healio.com/Psychiatry | 207 the original Patient Learning Center, but TABLE with additional courses in community resources and other “informed consum- Psychoeducation Topics at the er” subjects at two South Carolina state Patient Learning Center, Bryce Hospital hospitals.23 Week 1 Week 2 Week 3 Although not solely a psychoeduca- tion program, the Illness Management Orientation to patienthood Medication principles Stress management and Recovery program utilizes psycho- education as a component.24 This pro- Nutrition and health Family interactions Hazards of substance abuse gram has been endorsed as an evidence- What is mental illness Coping skills Communication skills based psychiatric consumer recovery program by the Substance Abuse and Illness monitoring and relapse Living effectively Community resources Services Administration prevention

(SAMHSA) of the US Department of Source: Bisbee CC, Vickar GM. Used with permission. Health and Human Services (DHHS); a toolkit is available from the SAMHSA website to enable full-fidelity imple- This program was the first such edu- (2-year-degree personnel), nurses, and mentation of the program. cational effort to be systematically avail- master’s level psychology staff, and was This toolkit provides implementation able at any inpatient or outpatient facil- directed by a doctoral level psychology information at the clinician, program ity throughout the state mental health staff member. Pre-and post-knowledge director, administrator, and state men- continuum of care in the country. In a was assessed through five-question sur- tal health department levels, as well as 1979 paper and a 1984 manual,26,27 Bis- veys on each topic. Patients completing videotapes, evaluation criteria (fidelity bee described an expansion of the PLC the program received a certificate of measures), and materials for distribution to include a comprehensive program of completion in a weekly graduation cer- to participants. subjects, description of psychiatric ill- emony. In addition to knowledge gain nesses, medications, coping skills, nu- measures, the program was evaluated PUBLIC PSYCHIATRIC SETTINGS trition and health, and other topics per- by patient satisfaction instruments and Before the 1970s, psychoeducation for tinent to patients with serious mental measures of changes in attitude toward patients with schizophrenia had not been illness (See Table). mental illness. offered in a structured format other than The program initially opened in a va- Documentation of the program was in small medication education groups and cated facility in the admissions unit on later expanded in a comprehensive man- classes. In the mid-1970s, a program was the campus of historic Bryce Hospital ual,28,29 which includes literature review, initiated at Bryce Hospital in Tuscaloosa, to serve patients admitted to the hospital introductory material program structure, AL, to teach a comprehensive array of primarily involuntarily through probate teaching topics, adult learning tech- topics related to patient management of court commitment. niques, media, and other topics pertain- schizophrenia and other serious mental The facility was renovated to serve as ing to establishment of a comprehensive illnesses. Osmond, Mullaly, and Bisbee classrooms, offices, and social gather- psychoeducation program for patients developed the patient education program, ing space, complete with all of the trap- with schizophrenia. initially called the Psychological Learn- pings of an educational facility — bul- Included are a 15-topic curriculum ing Center, later named the Patient Learn- letin boards, chalkboards, student desks, for patient education (focusing on edu- ing Center (PLC) at Bryce Hospital, Ala- and any educational materials available cation about serious mental illnesses, bama’s largest state psychiatric hospital. on schizophrenia, , and medications, nutrition and health, ill- The program initially consisted primarily severe depression. Patients were referred ness monitoring and relapse prevention, of a “Responsible Patient” class in which by their treatment teams for all or speci- skills for daily coping with symptoms, patients with schizophrenia, bipolar dis- fied parts of a 3-week program. and specific lessons about schizophre- order, or severe depression received in- The daily schedule included four nia, bipolar disorder, and depression). formation about their illnesses, medica- classes interspersed with ample nutri- The manual also includes: a 12-topic tion and other treatment, and their role in tion breaks and socialization time. Staff curriculum for families addressing the illness management.25 included mental health technicians etiology and treatment of mental illness;

208 | Healio.com/Psychiatry Healio.com The new online home of PSYCHIATRIC ANNALS 42:6 | June 2012 management skills (eg, relapse preven- PRIVATE SECTOR PSYCHIATRY partment and other high-intensity psy- tion); rights and responsibilities; and Believing it to be important to have a chiatric services. general coping skills. Specific handouts structured psychoeducational program in and slides are included for each topic, the hospital’s psychiatric service, Vickar REFERENCES 1. Lorig K, Gonzalez V, Laurent, D. The Chronic and permission is given to copy these and colleagues developed Schizophre- Disease Self-Management Workshop. Palo materials for use with patient and family nia Treatment and Education Programs Alto, CA: Stanford University; 2006. education sessions. (STEPS) in a private psychiatric setting 2. Lilly USA. Solutions for Wellness. Available at: www.solutionsforwellness.info/index.aspx. The psychoeducation program con- at Christian Hospital Northwest in St. Accessed May 31, 2012. tinued until the early 2000s, when it Louis. The program was based in part 3. McMichael, W. The Gold-headed Cane. Lon- was gradually reduced in scope due to on experience with the Patient Learning don: London: The Royal College of Physi- cians; 1968. decreasing lengths of stay of hospital Center (PLC) and the Nova Program in 4. Lamiani G, Furey A. Teaching nurses how to patients and decreasing funding levels Alabama, and in part on work by Abram teach: an evaluation of a workshop on patient for state hospital programming. After Hoffer, MD, and Moke Williams, MD, education. Patient Educ Couns. doi:10.1016/ several years of program operation in Fort Lauderdale, FL. jpec.2008.09.022 5. Parry C, Coleman EA, Smith JD, Frank JC, and expansion into the South Carolina This program and the PLC were the Kramer AM: The Care Transitions Interven- state hospital system, Kay McCrary, subjects of a symposium at the Institute tion: a patient-centered approach to facilitating EdD, concluded that psychoeducation on Psychiatric Services (then known as effective transfers between sites of geriatric care. Home Health Serv Q. 2003;22(3):1-18. for serious mental illness was a spe- Hospital and Community Psychiatry) 6. Ruitenbeek HM. The New Group Therapies. cialty intervention that required both and has continued to evolve with addi- New York: Avon Books; 1970. educational skills and fairly extensive tional components and materials. 7. Pepper B: Research, program, and clinical in- novations for the seriously mentally ill. 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Anthony WA: The Principles of Psychiatric successful completion of 4 days of — offers aftercare meetings and social Rehabilitation. Baltimore, MD: University intensive training, passing a content events for participants and other persons Park Press; 1979. 11. Pinkerton SS, Hughes H, Wenrich WW: Be- examination, and observed practice in the community. havioral Medicine: Clinical Applications. New teaching of a selected content topic.30 York: John Wiley & Sons; 1982. Program faculty consisted of pharma- CONCLUSION 12. Turkington D, Kingdon D, Weiden PJ: Cogni- cists, psychiatrists, nurses, psycholo- Research on psychoeducation for tive behavior therapy for schizophrenia. Am J Psychiatry. 2006;163:365-373. gists, social workers, and front-line patients with schizophrenia and their 13. Amdur M, Cohen M. Medication groups for psychoeducation instructors. This pro- families has shown the intervention re- psychiatric patients. 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Healio.com The new online home of PSYCHIATRIC ANNALS 42:6 | June 2012 Healio.com/Psychiatry | 209 18. Lewinsohn PM, Antonuccio DO, Steinmetz 23. McCrary K. Patient and Family Education Illness: A Practical Program Guide. Gaith- JL, Teri, L: The Coping with Depression Center Program Description/Procedure Man- ersburg, MD: Aspen Publishers; 1991. Course: A Psychoeducational Intervention ual. Columbia, SC: Bryan Psychiatric Hospi- 29. Bisbee C. Patient Education in Psychiatric Ill- for Unipolar Depression. Eugene, OR: Casta- tal; 1981. ness: A Practical Program Guide, edn 2. Pike lia Publishing; 1984. 24. SAMHSA. Illness Management & Recov- Road, AL: Bisbee & Associates; 1995. 19. Barter JT, Queirolo JF, Ekstrom SP: A psy- ery Toolkit. Available at http://store.samhsa. 30. Bisbee C, McCrary K: Training and cre- choeducational approach to educating chronic gov/product/Illness-Management-and-Re- dentialing professionals to provide patient mental patients for community living. Hosp covery-Evidence-Based-Practices-EBP-KIT/ (consumer) education. Paper presented at the Community Psychiatry. 1984;35:793-797. SMA09-4463. Accessed Dec. 4, 2011. meeting of the Curriculum and Training Net- 20. Ascher-Svanum H. A psychoeducational in- 25. Osmond H, Mullaly R, Bisbee C. The medical work of the National Alliance for the Men- tervention for schizophrenic patients. Patient model and the responsible patient. Hosp Com- tally Ill. Chicago, IL; July 1990. Educ Couns. 1989;14:81-87. munity Psychiatry. 1978;29(8):522-524. 31. Vickar G, North CS, Downs D, Marshall DL. 21. Ascher-Svanum H, Krause A: Psychoeduca- 26. Bisbee C. Patient education in psychiat- A randomized controlled trial of a private- tional Groups for Patients with Schizophre- ric illness. J Orthomolecular Psychiatry. sector inpatient-initiated psychoeducation nia: A Guide for Practitioners. Gaithersburg, 1979;8:239-247. program for schizophrenia. Psychiatric Ser- MD: Aspen Publishers; 1991. 27. Bisbee, C. Patient Education in Psychiatric vices. 2009;60(1). Available at: www.psychia- 22. Laffal J, Brown M, Pearlman LA, Burns GL: Illness: A Practical Program Guide. Unpub- tryonline.org. Accessed May 31, 2012. Therapeutic education of psychiatric inpatients in lished manuscript. 1984. a classroom setting. Q Rev Bull. 1983; 190-195. 28. Bisbee C. Patient Education in Psychiatric

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