Psychoeducation as Evidence-Based Practice: Considerations for Practice, Research, and Policy

Ellen P. Lukens, MSW, PhD William R. McFarlane, MD

This paper describes psychoeducation and its applications for and health professions across system levels and in different contexts by reviewing the range of applications that have appeared in the recent literature. The theoretical foundations of clinically based psychoeducation are reviewed and the common elements of practice are identified. Examples of well-defined psychoeducational interventions are presented that meet criteria for empirically supported psychological interventions. In conclusion, the broad applications of psychoeducation for health care and mental health practice and policy at both the clinical and community levels are discussed, and the need for further evaluation and research is considered. [Brief Treatment and Crisis Intervention 4:205–225 (2004)]

KEY WORDS: psychoeducation, group intervention, evidence-based practice, randomized trials, brief treatment.

Psychoeducation is among the most effective of This paper examines the research that supports the evidence-based practices that have emerged psychoeducation as evidence-based practice for in both clinical trials and community settings. the professions dealing with mental health, Because of the flexibility of the model, which health care, and social service across system incorporates both illness-specific information levels and in different contexts by reviewing and tools for managing related circumstances, the range of applications that have appeared in psychoeducation has broad potential for many the recent literature. We identified the psycho- forms of illnesses and varied life challenges. educational examples included in the review by following guidelines for evidence-based prac- tices created by the American Psychological From Columbia University School of Social Work (Lukens), and Department of Psychiatry, Maine Medical Center Association’s (APA) Task Force on Promotion (McFarlane). and Dissemination of Psychological Procedures Contact author: Ellen P. Lukens, PhD, Columbia University School of Social Work, 622 West 113th Street, (1995). In the Discussion section, the common New York, NY 10025. E-mail: [email protected]. and unique themes and content across studies DOI: 10.1093/brief-treatment/mhh019 and populations are identified.

Brief Treatment and Crisis Intervention Vol. 4 No. 3, ª Oxford University Press 2004; all rights reserved.

205 LUKENS AND MCFARLANE

Psychoeducation is a professionally delivered set the stage for within-group dialogue, social treatment modality that integrates and syner- learning, expansion of support and coopera- gizes psychotherapeutic and educational in- tion, the potential for group reinforcement of terventions. Many forms of psychosocial positive change, and network building (Pen- intervention are based on traditional medical ninx et al., 1999). They reduce isolation and models designed to treat pathology, illness, serve as a forum for both recognizing and liability, and dysfunction. In contrast, psycho- normalizing experience and response patterns education reflects a paradigm shift to a more among participants, as well as holding profes- holistic and competence-based approach, stress- sionals accountable for high standards of ing health, collaboration, coping, and empow- service. Cognitive-behavioral techniques such erment (Dixon, 1999; Marsh, 1992). It is based as problem solving and role-play enhance the on strengths and focused on the present. The presentation of didactic material by allowing patient/client and/or family are considered people to rehearse and review new informa- partners with the provider in treatment, on tion and skills in a safe setting. These can the premise that the more knowledgeable the be amplified through specific attention to the care recipients and informal caregivers are, the development of stress management and other more positive health-related outcomes will be coping techniques (Anderson et al., 1986; for all. To prepare participants for this partner- McFarlane, 2002). Narrative models, in which ship, psychoeducational techniques are used to people are encouraged to recount their stories as help remove barriers to comprehending and related to the circumstances at hand, are used to digesting complex and emotionally loaded in- help them recognize personal strengths and formation and to develop strategies to use the resources and generate possibilities for action information in a proactive fashion. The assump- and growth (White, 1989). tion is that when people confront major life Recent mandates at both the federal and challenges or illnesses, their functioning and international levels have pushed to include focus is naturally disrupted (Mechanic, 1995). psychoeducation as a focal point in treatment Psychoeducation embraces several comple- for and other mental illnesses, mentary theories and models of clinical prac- and are backed by national policymakers tice. These include ecological systems theory, (President’s New Freedom Commission on Men- cognitive-behavioral theory, learning theory, tal Health, 2003) as well as influential family group practice models, stress and coping self-help groups such as the National Alliance models, social support models, and narrative for the Mentally Ill (NAMI) (Lehman & Stein- approaches (Anderson, Reiss, & Hogarty, 1986; wachs, 1998; McEvoy, Scheifler, & Frances, Lukens, Thorning, & Herman, 1999; McFarlane, 1999). Based on an exhaustive review of the Dixon, Lukens, & Lucksted, 2003). Ecological evidence-based literature on schizophrenia, the systems theory provides the framework for Schizophrenia PORT (Patient Outcomes Re- assessing and helping people understand their search Team) study recommended that educa- illness or experience in relation to other systems tion, support, crisis intervention, and training in their lives (i.e., partners, family, school, in problem solving be offered to available health care provider, and policymakers). Under family members over a period of at least 9 this umbrella, psychoeducation can be adapted months (Lehman & Steinwachs, 1998). Best- for individuals, families, groups, or multiple practice and expert panels corroborated these family groups. Although psychoeducation can recommendations (American Psychiatric Asso- be practiced one-on-one, group practice models ciation, 1997; Coursey, 2000; Coursey, Curtis, &

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Marsh, 2000; Frances, Kahn, Carpenter, Doch- coordination (i.e., easy access and clarity of erty, & Donovan, 1998), given that remarkably expectation regarding service, medication man- positive outcomes have been observed in over agement and adherence, and crisis planning), 25 independent studies (Dixon, Adams, & provision of relevant up-to-date information in Lucksted, 2000; Dixon et al., 2001; McFarlane a timely and flexible manner, attention to et al., 2003). Several outcomes of psychoeduca- family conflict, communication, loss, problem tional interventions for schizophrenia are solving, and attention to social as well as particularly noteworthy and have been dem- clinical needs for the person with illness, along onstrated across studies (McFarlane et al., with expanded social support for the family, 2003). For persons receiving individual therapy through multiple family psychoeducation and and medication, or medication alone, the 1-year family support groups (e.g., NAMI) (Dixon relapse rate ranges from 30% to 40%; for those Adams, & Lucksted, 2000; McFarlane et al., participating in family psychoeducation of at 1995; McFarlane et al., 2003). least 9 months’ duration, the rate is about 15% Psychoeducational approaches also are well (Baucom, Shoham, Mueser, Daiuto, & Stickle, established as adjunctive treatment for cancer, 1998). Other positive outcomes have been docu- where patients and families are struggling with mented for patients and for families as well, different forms of challenge. Although persons suggesting that psychoeducation provides mul- with cancer typically fall into the normal range tiple benefits. These include decreased symp- in terms of psychological processes, they tomatology and improved social functioning for inevitably struggle with the and de- the patient (Dyck, Hendryx, Short, Voss, & pression following the extraordinary stress McFarlane, 2002; Dyck et al., 2000; McFarlane associated with the diagnosis and treatment of et al., 1995; Montero et al., 2001) and improved the cancer (Cunningham, Wolbert, & Brock- well-being and decreased levels of medical meier, 2000). Numerous randomized studies illness among family members (McFarlane, over the last two decades have shown signif- Dushay, Stastny, Deakins, & Link, 1996; Solo- icantly increased quality of life and decreased mon, Draine, & Mannion, 1996; Solomon, levels of anxiety and distress for persons with Draine, Mannion, & Meisel, 1996). cancer who participate in professionally led In schizophrenia, any form of intervention is psychoeducational groups (Cunningham, 2000; complicated by the symptoms of the illness, Edmonds, Lockwood, & Cunningham, 1999; which include as well as functional Meyer & Mark, 1995). There is increasing and cognitive deficit or distortion, alogia, evidence that psychoeducational and other inertia, denial, and/or lack of awareness of forms of professionally led support groups can illness (American Psychiatric Association, have an impact on the longevity of cancer 1994). Patients, formal care providers, and patients as well (Cunningham, 2000; Cunning- informal caregivers are confronted not only ham, Edmonds, et al., 2000; Fawzy, Fawzy, by the severe burden of the illness, but by the Arndt, & Pasnau, 1995; Richardson, Shelton, distorted sense of reality by which it is Krailo, & Levine, 1990; Richardson, Zarnegar, characterized. To address this multifaceted set Bisno, & Levine, 1990; Spiegel, Bloom, Kraemer, of challenges, the various psychoeducational & Gottheil, 1989). This reinforces the value and models for schizophrenia build on a series of importance of emotional support and enhanced principles that exemplify the paradigm shift to coping in the face of any form of severe illness. a strengths-based approach to intervention. Families and other informal caregivers of Key aspects of these approaches include service persons with cancer have been targeted as well.

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 207 LUKENS AND MCFARLANE

In one recent study focusing solely on partners 1998; Chambless & Ollendick, 2001). Broadly of women with early-stage breast cancer, par- defined, these criteria are grouped as: ticipants in psychoeducational groups showed less mood disturbance 3 months posttreatment Category I: established, efficacious, specific than controls, and the women whose partner interventions, including two rigorous participated reported less personal mood dis- randomized trials conducted by indepen- turbance and more emotional support (Bultz, dent investigators; Speca, Brasher, Geggie, & Page, 2000). These Category II: probably or possibly efficacious women also described significantly more stable intervention, treatment compared with marital relationships over time, suggesting that wait-list control; and the psychoeducational groups served a preven- tive function. Category III: experimental treatments that do The number of well-documented evidence- not meet the above criteria for adequate based studies on psychoeducation as an methodology. intervention for illnesses as different as schizo- phrenia and cancer suggests the potential for In addition, the task force determined that the model. There is significant evidence that Category I interventions should follow a treat- psychoeducational interventions are associated ment manual or clearly prescribed outline for with improved functioning and quality of life, treatments and that the characteristics of the decreased symptomatology, and positive out- sample should be specified (Chambless & comes for both the person with illness and Hollon, 1998). Nathan and Gorman (1998) family members as well. extend the characteristics for Category I studies However, there has been little attempt to to include blind assessment of research subjects examine the breadth of applications in other by independent raters, specific inclusion and psychiatric, medical, or clinical settings. The exclusion criteria, up-to-date diagnostic assess- aim of this paper is to review and discuss the ment, and adequate statistical power. range of psychoeducational interventions for Studies selected for inclusion in this review other settings and circumstances using ac- were retrieved through a search of PubMed and cepted criteria for designating a practice inter- PsychInfo from 1995 until the present. This vention as evidence based. time period was selected because of increased attention to selection criteria for evidence- based practice that has emerged since 1995 Method (Chambless & Hollon, 1998; Chambless & Ollendick, 2001; Rousanville, Carroll, & Onken, Our approach is twofold: first, to show the 2001). Key search words included psychoeduca- breadth of application for psychoeducational tion, psychoeducational groups, randomized trial, interventions, and second, to include studies control group, clinical trial, controlled trial, and that follow the criteria for empirically sup- outcome. The intent was to identify studies that ported psychological interventions devised by would meet criteria for Category I, as described the Task Force on Promotion and Dissemination above. of Psychological Procedures (1995). These For the purposes of this review, the following guidelines have been supported and amplified criteria were used for the selection of published by other investigators and reported on by studies described as using a psychoeducational Chambless and colleagues (Chambless & Hollon, intervention:

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The article focused on one or more inter- (Shelton et al., 2000). A second was excluded ventions targeting a specific and clearly because a psychoeducational group was used as defined mental illness, medical illness, or a minimally defined control intervention (Lati- other form of personal life challenge (e.g., mer, Winters, D’Zurilla, & Nichols, 2003), and partner abuse). a third because psychoeducation was referred At least one of the interventions labeled as to as a combination placebo/usual care control an active treatment was described as with no description as to form or content psychoeducational in nature, targeting (Kaminer, Burleson, & Goldberger, 2002). either the family, the person challenged by the illness or life situation, or both. Applications for Mental Health The psychoeducational intervention was Conditions Other Than Schizophrenia presented in person (as opposed to online or solely through written material). Although reports of randomized trials of The design of the study involved random psychoeducation for adults coping with schizo- assignment to the active psychoeduca- phrenia are well represented in the literature, tional treatment intervention and to adaptations for children and adolescents and for a control group. (Note that in one in- adults with other serious mental health con- stance, reports of randomized trials in ditions are just beginning to appear (see Table process are included in the review as well, 1). Fristad and her colleagues piloted multiple because they are based on a well-docu- family psychoeducational groups with break- mented and randomized pilot study [Fris- out sessions for children aged 8 to 11 with mood tad, Gavazzi, & Mackinaw-Koons, 2003; disorders (including both and Fristad, Goldberg-Arnold, & Gavazzi, major depressive disorder/dysthymia as com- 2003]). pared with wait-list controls [Fristad, Gavazzi, The article provided enough information to & Soldano, 1998; Fristad, Goldberg-Arnold, & assess the quality of the research design Gavazzi, 2002]). These groups focused on both and methods and the applicability and parent and child outcomes, including caregiver relevance of outcome measures. knowledge, increased caregiver concordance regarding diagnosis and treatment, decreased The article provided enough information to expressed emotion in parents and environmen- assess the nature and extent of the tal stress for the child, and reduced symptom psychoeducational intervention, to deter- severity and duration for the child. The cur- mine whether psychotherapeutic and riculum particularly attended to information educational techniques were integrated. dissemination, the building of advocacy and Intervention studies in which the authors communication skills, both within the family referred to a seemingly straightforward and across systems, and strategies for social educational intervention (i.e., with no problem solving and symptom management. psychotherapeutic component) as psy- Outcomes were positive, with families engaged choeducational in nature were excluded. in the psychoeducational groups showing significantly more knowledge about mood One article was not reviewed because the symptoms, increased use of support services, term psychoeducation was referred to in the title and increased reports of parental support by and abstract but not in the text of the article children, both immediately after and 4 months

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Active (PE) Significant Treatment Structure Outcomes Study Sample/Dx Design Protocol and Duration for PE Commenta

Colom Outpatients Randomized trial: Symptoms, course, 21 sessions Reduced # total Category II. et al., 2003 diagnosed with PE groups vs. communication, & relapse & # Well-designed study bipolar I & II disorder. nonstructured coping skills relapses/person. Conducted in Spain group meetings Increased time to recurrence; fewer & shorter hospitalizations Dowrick Adults with Randomized trial; Relaxation, 12 two-hour Both active Category II. et al., 2000 depression group PE vs. positive thinking; sessions over 8 interventions Separates PE & in community individual problem social skills weeks w/class reduced caseness problem solving solving vs. controls. reunions & improved N = 452 subjective function.

: al2004 Fall 4:3 Problem solving more well received Fristad et al., Children with Pilot study; Decrease in symptoms; Multiple family Improved family Category II 1998, 2002 mood disorders randomized improve coping & groups with climate trial in process communication; break-out groups stress management; for children/ expanded social supports adolescents. Late afternoon & evening Honey Women Randomized trial: PE Coping strategies 8 sessions Tx group less Category II et al., 2003 diagnosed with groups for women vs. related to child depressed at postnatal standard tx. N =45 care & obtaining posttest & depression social support; 6-month fu, cognitive-behavioral controlling for techniques & antidepressants relaxation TABLE 1 continued. Mental Health Conditions

Active (PE) Significant Treatment Structure Outcomes Study Sample/Dx Design Protocol and Duration for PE Commenta

No differences re social support, strength of marriage, or coping Miklowitz Persons with Randomized trial; PE, with focus on 21 individual Patients showed Category II. et al., 2003 bipolar disorder & individual PE for communication & sessions w/ family fewer relapses. Well-designed study family families vs. crisis problem-solving & patient over Longer survival, intervention for training 9 months greater reduction re ramn n rssItreto / Intervention Crisis and Treatment Brief families. in mood disorder All patients symptoms & better received medication. medication N = 101 compliance Peterson Women Randomized trial; Review of PE 14 one-hour All active tx Category II. et al., 1998 with binge therapist-led PE vs. information, stress group sessions showed decrease Small sample partial self-help vs. management, over 8 weeks in binge eating size per cell; structured self-help vs. homework at posttest group randomization.

wait-list control. Manual based Practice Evidence-Based as Psychoeducation N =61 Rea et al., 2003 Outpatients Randomized trial; PE about bipolar 21 one-hour Patients less Category II. diagnosed individual family disorder, communication sessions likely to be Well-designed study. with bipolar I PE vs. individual tx enhancement, problem hospitalized; Manual based disorder & for patient. N =53 solving. fewer relapses their families As-needed crisis over 2 years : al2004 Fall 4:3 intervention

Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up.

aChambless criteria for evidence-based practice (Chambless & Hollon, 1998). 211 LUKENS AND MCFARLANE

posttreatment. Interestingly, parents reported compared group psychoeducation (12 two-hour increased positive family interactions, but not sessions over 8 weeks), 6 individual problem- decreased negative family interaction. solving sessions conducted at home and con- The authors successfully included children trols. The authors found that the two active with two different diagnoses (bipolar disorder interventions reduced symptoms and improved and major depression/dysthymia) in each subjective functioning. The patients particu- group. This represented an accommodation to larly liked the individual problem-solving practicality (i.e., ease of scheduling), and sessions. Interestingly, the authors utilized families appeared to benefit from learning about problem solving as a treatment independent both disorders. Fristad and colleagues recently of psychoeducation. This is in contrast to most reported on two randomized trials to test two of the studies reviewed, which specifically variations on the pilot; one that serves families incorporated problem-solving techniques with- through eight multiple family psychoeduca- in the definition of psychoeducation. tional groups, and a second parallel model that In a study conducted in Spain of outpatients includes 16 individual family psychoeducation diagnosed with bipolar disorder type I and II, sessions (parent-only meetings alternating with Colom and colleagues (2003) compared the child sessions in which parents join at the impact of 21 psychoeducational group sessions beginning and end of the session) (Fristad, with nonstructured group meetings. Partici- Gavazzi, et al., 2003; Fristad, Goldberg-Arnold, pants in the active treatment were less likely to et al., 2003). relapse overall, had fewer relapses per person, Honey, Bennett, and Morgan (2003) tested increased their time to recurrence of symp- a brief psychoeducational group intervention toms, and had both fewer and shorter hospital- for postnatal depression, randomly assigning izations. In a relatively small study (N ¼ 53), 45 Welsh women scoring above 12 on the Rea and colleagues (2003) compared outcomes Edinburgh Postnatal Depression Scale to an for patients involved in 21 individual family eight-session psychoeducational group or to psychoeducation sessions with standard in- routine treatment. The partner was not in- dividual treatment. Participants in the family volved. Although not manual based, the in- psychoeducation sessions were less likely to tervention followed a prescribed curriculum relapse or be hospitalized over the 2-year and included coping strategies related to child study. In a separate, larger study, Miklowitz, care and obtaining social supports, cognitive- George, Richards, Simoneau, and Suddath behavioral techniques, and relaxation. At post- (2003) randomized 101 individuals with bi- test and 6 months posttreatment, women in the polar disorder to either 21 individual psycho- psychoeducational groups showed significantly educational family sessions or crisis decreased scores on the depression measure, management (2 educational sessions plus crisis controlling for antidepressant use. However, no sessions as needed). The patients in the differences occurred in terms of improved psychoeducational treatment showed fewer social support, marital relationship, or coping relapses overall, longer symptom-free periods, in analyses of effects for time, group, or Time fewer symptoms, and better medication com- Group interaction. pliance. Both of these studies were manual Several studies addressed the needs of based, with similar design, method, approach, persons diagnosed with depression or bipolar and outcome. However, the studies together disorder living in the community. In a three- cannot be labeled as meeting criteria for armed study, Dowrick and colleagues (2000) a Category I evidence-based practice because

212 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Psychoeducation as Evidence-Based Practice they share an investigator (Chambless & and reaction also showed a significant decrease Hollon, 1998). for caregivers who received psychoeducation. Peterson and colleagues (1998) used a psycho- However, there were no significant differences educational intervention for women with binge between groups for the secondary patient- eating disorder, comparing it with three other outcome measures. treatment conditions (partial self-help, struc- In a small study conducted in southern India, tured self-help, and a wait-list control). This Russell, al John, and Lakshmanan (1999) was the only study reviewed in which partic- randomly assigned 57 parents of children with ipants in the psychoeducational intervention intellectual impairment to either an active did not show superior outcomes over time. psychoeducational group intervention or an Rather, participants in all active treatments untreated control group. Participants in the 10- showed a decrease in binge eating immediately session groups showed significantly improved posttreatment. The authors noted several parental attitude regarding child rearing and threats to the validity of their study: random- management of the disability immediately ization that targeted groups rather than indi- posttest. viduals, small sample size (N ¼ 61), and lack of follow-up data. Applications for Medical Illness

Applications for Caregivers of Persons Psychoeducational programs have also been With Mental Health Conditions devised for medical illnesses, including acute and life-threatening illnesses other than cancer, Two studies particularly addressed the needs of as well as more chronic conditions. These caregivers (see Table 2). Hebert and colleagues programs aim to help both the persons affected (2003) tested the efficacy of a 15-session series and their caregivers or partner weather both of psychoeducational groups for informal care- the physical and the psychological impact of givers of persons with dementia in comparison chronic and acute illness (see Table 3). with traditional support groups. Randomiza- In one of the cross-national studies identified tion involved 158 individuals stratified by sex through this review, researchers in Hong Kong and kinship status at several different sites. The (Cheung, Callaghan, & Chang, 2003) randomly psychoeducational content in the curriculum assigned 96 women aged 30 to 55 preparing for was focused on stress appraisal and coping. elective hysterectomy to either individual Primary outcome measures were blindly as- psychoeducational sessions (information book- sessed and included frequency and response to let plus cognitive interventions focusing on behavioral problems among care receivers; distraction and reappraisal) or a control group secondary measures included patient burden, (information booklet without additional in- distress and anxiety, perceived social support, formation). Number of sessions, duration, and and self-efficacy. Immediately following the intensity for the experimental group were not intervention, those assigned to the psycho- specified and it was difficult to tell how well educational groups reported significantly less integrated the educational component was with reaction to behaviors and a trend toward less the cognitive techniques in the psychoeduca- frequency of reported behavior problems tional intervention. However, women receiving among the family members with dementia. the active treatment reported significantly The interaction between behavior frequency lower anxiety and pain and higher treatment

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TABLE 2. Caregivers of Persons With Mental Health Conditions

Active (PE) Significant Treatment Structure and Outcomes Study Sample/Dx Design Protocol Duration for PE Commenta

Hebert Informal caregivers Multisite Stress appraisal 15 sessions Tx group shows Category II et al., 2003 of persons with randomized trial; and coping less reaction to dementia PE groups vs. behavior of patient, traditional support less frequency of groups. N = 158 reported problem stratified by sex behaviors. No

: al2004 Fall 4:3 & kinship status difference in burden, distress & anxiety, perceived social support, or self-efficacy Russell Parents of Randomized trial; Interactive 10 sessions Tx group showed Category II. et al., 1999 children with PE groups for group PE improved parental Small total intellectual parents vs. control attitude re child sample size disability. group. N =57 rearing & management Conducted in of disability southern India

Note: Dx = diagnosis; PE = psychoeducation; tx = treatment.

aChambless criteria for evidence-based practice (Chambless & Hollon, 1998). Psychoeducation as Evidence-Based Practice satisfaction than those in the control group in eral life satisfaction, and self-efficacy, and the days immediately postoperative. There was a trend toward improved mental health and no difference between the two groups in social functioning. No differences emerged requests for painkillers postsurgery. between the groups either in terms of de- Two additional models addressed chronic pression and uncertainty regarding future medical problems, specifically obesity and functioning or on measures from the Medical generalized pain. Ciliska (1998) randomly Outcomes Short Form (Ware & Sherbourne, assigned 78 women with obesity to a small- 1992) on physical functioning and general group psychoeducational intervention (6 to 8 health. It is noteworthy that those who people per group), to an education-alone group dropped out or refused the active treatment using a classroom format (16–20 people), or to (8%) appeared to be more affected by pain (i.e., an untreated control group. The model empha- unable to sustain employment) than those who sized problem solving and assertiveness train- enrolled and participated (LeFort & Steinwachs, ing, with attention to etiology, risks and 1998). This suggests that the experience of benefits; and the relationship between body severe pain may interfere with willingness or image and self-esteem. Immediately posttreat- ability to participate in a group intervention. ment, the psychoeducational subjects showed Olmsted, Daneman, Rydall, Lawson, & Rodin significantly increased self-esteem, body satis- (2002) assigned 85 adolescent girls diagnosed faction, and more restrained eating patterns with type I diabetes and comorbid disturbed compared with participants in either of the two eating patterns and their parents to either other groups. Outcomes for participants in the a series of six psychoeducational group sessions education-alone intervention did not differ or a treatment-as-usual control group. The girls from those in the control group. and parents participated in separate but parallel Unremitting physical pain is associated with sessions. At 6-month follow-up, the girls in the depressive symptoms such as distress, hope- active treatment continued to show significant- lessness, and despair and contributes to dis- ly reduced eating disturbance compared with ruption in both individual and family the controls. functioning. To address this set of problems, LeFort, Gray-Donald, Rowat, and Jeans (1998) devised a 12-hour psychoeducational model Applications for Other Clinical Settings adapted from the Arthritis Self-Management and Prevention Program (Lorig, 1986) for persons confronted with chronic pain. Curriculum was focused on Programs designed for other life concerns facts and myths regarding pain, medication, familiar to social service agencies, exclusive of depression, and nutrition in the context of those directly related to either psychiatry or problem solving, communication skills, and medicine, have also begun to appear in the lit- mutual support. The authors randomly as- erature (see Table 4). Gibbs, Potter, Goldstein, signed 110 individuals diagnosed with chronic and Brendtro (1996) created a manual-based pain (mean duration of pain, 6 years) to either psychoeducational program for adolescents in- the psychoeducational groups or a 3-month carcerated in a medium security youth correc- wait-list control. Immediately posttreatment, tional facility. The psychoeducational groups the group participants showed significantly met daily and focused on mediation, skills reduced indicators of pain and dependency, and values enhancement, and peer support. improved physical functioning, vitality, gen- Adolescents were taught to recognize negative

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 215 UESADMCFARLANE AND LUKENS 1 re ramn n rssItreto / Intervention Crisis and Treatment Brief 216 TABLE 3. Medical Illness

Significant Active (PE) Treatment Structure and Outcomes Study Sample/Dx Design Protocol Duration for PE Commenta

Cheung Women age 30 Randomized trial; Information plus Not specified Tx group Category II. et al., 2003 to 35 preparing individual PE sessions cognitive intervention lower Extent and nature for elective vs. control group (info with attention to anxiety & pain; of PE not defined hysterectomy booklet only). N =96 distraction & reappraisal higher tx of circumstance satisfaction. No difference in request for pain medicine postsurgery Ciliska, 1998 Women with Randomized trial Education about obesity; 12 sessions over Tx group increased Category II obesity comparing PE problem solving, 12 weeks; 2-hour self-esteem & group, education assertiveness training; sessions; 68 women restrained eating;

: al2004 Fall 4:3 alone, & control. body image work; increased body N =78 group support satisfaction LeFort People with Randomized trial Definitions of pain, 6 weeks, 12 hours Short-term Category II. et al., 1998 chronic comparing PE myth busting; improvement Well-defined study physical pain group w/ 3-month cognitive-behavioral of pain severity wait-list control. techniques; pain & impact, role N = 110 management; group functioning & problem solving; involvement, life communication satisfaction, skills & mutual support self-efficacy, resourcefulness; decreased dependency. No difference re depression, uncertainty, general health, or physical functioning Psychoeducation as Evidence-Based Practice

social behavior both in themselves and among a their peers and to replace these behaviors with more constructive and affirmative re- sponses and actions. In a randomized pilot Category II. Manual based study, participants in the psychoeducational groups were described as dramatically easier to manage, with significantly improved social skills and adjustment and decreased antisocial behavior. However, sample size, duration of treatment, and time to follow-up were not Significant Outcomes for PE Comment Reduction in eating disturbance; maintained at 6-month fu specified. In a small randomized trial conducted in Hawaii, Kubany, Hill, and Owens (2003) assigned 37 ethnically diverse women with both a history of partner abuse and a diagnosis of posttraumatic stress disorder (PTSD) to either an individually based psychoeducational pro- Structure and Duration Separate group sessions for girls and parents 6 weekly 90-minute group sessions. gram or a wait-list group. Most of the women (32) eventually completed the program. The active intervention incorporated 8 to 11 in- dividual one-and-a-half-hour sessions, focusing on explorations of trauma history, stress man- agement, monitoring of negative self-talk, as- sertiveness, managing contact with the abuser, and strategies for self-advocacy and avoid- Active (PE) Treatment Protocol PE content, sociocultural influences, strategies to control symptoms ing revictimization. At posttreatment and 3- month follow-up, 94% of the women no longer met criteria for PTSD. Moreover, they showed significantly reduced depression, guilt, and =85 shame, and increased self-esteem. In contrast, N those women assigned to the wait-list group

Randomized trial comparing PE group w/ tx as usual. showed no changes in scores for any measure at the second pretest. Although the sample size was extremely small, the authors documented positive results across ethnic groups, suggest- ing that the themes addressed in the psycho- educational groups (i.e., male dominance and the status of women relative to men) were Medical Illness

. universal issues. Adolescent girls with type I diabetes & disturbed eating attitudes & behavior, and parents Another study involved groups of partici- pants from the general population and was continued designed to promote health attitudes and

: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up. behaviors regarding nutrition and as a pre- Chambless criteria for evidence-based practice (Chambless & Hollon, 1998). TABLE 3 Olmsted et al., 2002 Note a Study Sample/Dx Design ventive technique for the development of

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TABLE 4. Other Clinical Settings and Prevention

Active (PE) Significant Treatment Structure and Outcomes Study Sample/Dx Design Protocol Duration for PE Commenta

Gibbs Antisocial youth/ Randomized PE Strengths-based; Daily meetings, 6090 Pilot data: Active tx: Clear summary of et al., 1996 medium-security group vs. control. peer group mediation, minutes; 79 youth. 15% recidivism at theory & conceptual youth correctional Pilot data; N not skills training, anger Duration & leadership 6 mos. & 1 year. model facility reported management, moral not described Controls: 30% at education 6 mos.; 41% at 1 year Kubany Women with Randomized Exploration of 8to11 At posttx, 94% did Category II. et al., 2003 hx of partner individual PE trauma hx, stress hour-&-half not meet PTSD criteria; Small sample abuse plus PTSD sessions vs. management, sessions reduced depression,

: al2004 Fall 4:3 wait-list control. assertiveness, guilt, shame, increased N =37 managing contact self-esteem. with batterer, Wait-list controls strategies for showed no change self-advocacy & at second pretest avoiding victimization Rocco Adolescent girls Random assignment Focus on normal 9 monthly Tx group showed Prevention-oriented et al., 2001 in affluent high to PE groups vs. developmental sessions reduced bulimic study; nonclinical school in Italy; no-group controls transitions, risk factors attitudes, tendency sample prevention of for eating disorders, to asceticism, eating disorders social challenge, ineffectiveness, anxiety, & body shape, & weight fears about maturity

Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; hx = history; PTSD = posttraumatic stress disorder.

aChambless criteria for evidence-based practice (Chambless & Hollon, 1998). Psychoeducation as Evidence-Based Practice eating disorders (see Table 4). Rocco, Ciano, and cant others can be identified from this group of Balestrieri (2001) randomly assigned adolescent studies (see Tables I through IV) and are girls from an affluent high school in Italy to consistent with those used in the work on receive either nine monthly sessions in in- schizophrenia and cancer. These include tensive psychoeducational groups or no in- changes in symptoms (i.e., symptom reduction tervention. The program targeted normal specific to the targeted illness or situation), developmental transitions as well as known decreased anxiety and depression (regardless of risk factors for eating disorders, with attention problem and setting), and less time between to body shape and weight, social challenges, acute episodes of illness. They also include and academic achievement. Compared with the increased adherence to and overall satisfaction controls, participants showed reductions in with medication and treatment, knowledge, bulimic attitudes, in tendency to asceticism, self-esteem and resources, family/marital cli- and in feelings of ineffectiveness, as well as mate or adjustment, and quality of life. lowered anxiety and fears about maturity. However, measures of process—including attendance, dropout, turnover, training of facilitators, and fidelity of treatment—cannot Discussion be so clearly identified. Although these are more characteristic of evaluation studies than In reviewing this relatively small number of randomized trials, such data would help to studies, it is clear that all fall into Category II in inform future studies. In addition, assessment terms of the APA criteria for evidence-based of resilience and competence, designated as practice (Chambless & Hollon, 1998; Chambless integral to the strengths-based psychoeduca- & Ollendick, 2001; Task Force on Promotion tional process, would contribute knowledge and Dissemination of Psychological Procedures, regarding the unique and irreducible aspects of 1995). None of the studies reviewed would meet the approach (Anderson et al., 1986; Cunning- the criteria for Category I, because they either ham, 2000; McFarlane et al., 2003). These are not sufficiently rigorous, have not been include measures of the ability to act and replicated by independent investigators, or change, willingness to initiate change, appli- both. However, reviewing the limitations and cation to self-help work, and quality of rela- strengths of these studies is instructive so tionships with others and everyday experience. that potential investigators can anticipate the Other limitations can be identified in the challenges involved in designing and conduct- studies reviewed in terms of both conceptual ing effective psychoeducational interventions approach and research design. These include across diagnostic groups and settings. issues regarding sampling strategies, sample size, and statistical power; measurement (both process and outcome); analysis; and clinical Limitations and Strengths of the Studies definition. As regards sampling, several prob- The assessment tools and methods that are lems appear. There is almost no variability in common across the studies identified in this ethnicity within the studies reviewed, with the paper extend our understanding of how exception of Kubany et al.’s (2003) work on psychoeducational interventions can be consis- women who have been battered and suffer from tently evaluated. Several recurring parameters PTSD. In addition, only two of the studies of measurement for assessing the impact of provide information on independence and psychoeducation on participants and signifi- blindedness among assessment staff and de-

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scribe inclusion/exclusion criteria for study fidelity of treatment and to ensure potential for participants (LeFort et al., 1998; Russell et al., efficacy and replication. Some established 1999). investigators have addressed this by providing Both specificity as to follow-up and efforts to access to their materials through the public assess sustained impact of the interventions domain. For example, Sherman’s (2003) psycho- over time are lacking in some of the studies educational curriculum for families of persons reviewed as well. Work is also needed to assess with mental illness is available on the Internet, when and for whom psychoeducational inter- and McFarlane’s work on psychoeducational ventions do not work. Addressing these limi- multiple family groups for schizophrenia is tations would involve identifying the available through the evidence-based practices multideterminant and ‘‘optimal’’ measures for project sponsored by the Substance Abuse and each illness or set of circumstances for the Mental Health Services Administration and the individual, family unit, individual family Robert Wood Johnson Foundation (Steering members, and the community. Attending to Committee, 2003). the profiles of those who reject or drop out of this form of intervention is also critical. Summary and Conclusions Qualitative approaches may be needed to assess subjective response to intervention, motiva- In summary, this review indicates that psycho- tion, emotional availability, and readiness to educational interventions have been applied in process information or participate in a group a wide range of settings across system levels, intervention (Cunningham, 2000; McFarlane although to date only those addressing schizo- et al., 2003). phrenia and cancer can be considered evidence Another factor that interferes with the ability based. A breadth of programs using this flexible to replicate studies has to do with how the modality have emerged, as professional health investigators understand and present the clin- care workers have become increasingly aware ical determinants of psychoeducation in each of the critical role that familial and other study. Given the breadth of applications cited informal sources of support play in health in this paper, it is inevitable that the docu- outcome, successful functioning, and quality of mented interventions would vary greatly in life in several illnesses. As medical and intensity, duration, and content. However, the psychiatric care have become less contiguous term psychoeducation is used inconsistently as and all aspects of medical care have become well, and at least one study referred to the more specialized and fragmented, continuity of intervention as atheoretical (Bultz et al., 2000). care and knowledge regarding individual sit- To address these inconsistencies, efforts are uations has become increasingly difficult to needed to further articulate the common and maintain and coordinate among professional situation-specific aspects of psychoeducational providers (Lasker, 1997). This has been wors- curriculum where possible, as well as structure, ened by policy changes in the health care duration, and organization of content (Cun- environment involving managed care and in- ningham, 2000; McFarlane et al., 2003). As creasingly consolidated or truncated services specified in the APA task force on empirically (House, Landis, & Umberson, 1988; McDonald, supported practice (Task Force on Promotion Stetz, & Compton, 1996; Mechanic, 2002; and Dissemination of Psychological Procedures, Pescosolido, Wright, & Sullivan, 1995). 1995), access to a well-defined treatment Psychoeducational interventions appear to manual is essential as a precursor to measuring be sufficiently flexible to circumvent some of

220 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Psychoeducation as Evidence-Based Practice the dangers. To date, they have been used implementation, and second, to determine successfully either as primary or adjunctive acceptance and broad-based integration of the treatment, as part of a strategic program for pre- approach at the service level (Cunningham, vention, or as an experiential training tool for 2000; Dixon, Goldman, & Hirad, 1999; McFar- patients and their families in a range of settings lane et al., 2003). (Cunningham, Wolbert, et al., 2000; Lukens, Psychoeducation has the potential to extend Thorning, & Herman, 1999; McFarlane et al., the impact of care provision well beyond the 2003; Thase, 1997). However, additional efforts immediate situation by activating and reinforc- are needed to fully define psychoeducation at ing both formal and informal support systems the clinical, community, and professional levels (Caplan & Caplan, 2000; Lundwall, 1996; as applied to various settings and populations, Pescosolido, Wright, & Sullivan, 1995) and and to further identify how emerging and state- teaching individuals and communities how to of-the-art professional knowledge can be in- anticipate and manage periods of transition and tegrated into such programs. Existing programs crisis. If developed and implemented carefully, that show preliminary success for conditions following specified guidelines for delivering other than schizophrenia or cancer must be and documenting evidence-based practices successfully replicated under rigorous condi- (Task Force on Promotion and Dissemination tions before they meet the stringent criteria for of Psychological Procedures, 1995), psycho- evidence-based practice laid out by the APA educational interventions have far-reaching (Chambless & Hollon, 1998; Task Force on application for acute and chronic illness and Promotion and Dissemination of Psychological other life challenges across levels of the public Procedures, 1995). health, social and civic services, and/or educa- To better establish efficacy and effectiveness, tional systems. research designed to evaluate the impact of the interventions on outcomes over time and in a range of settings is critical. To conduct such References studies, clear and readily available treatment goals and principles, carefully defined process American Psychiatric Association. (1994). and outcome measures, and curriculum and Diagnostic and statistical manual of mental training manuals are needed to facilitate im- disorders (4th ed.). Washington, DC: Author. plementation and replication by mental health American Psychiatric Association. (1997). Practice and health professionals, educators, and re- guideline for the treatment of patients with searchers. At the individual and family level, schizophrenia. American Journal of Psychiatry, measures of outcome should include knowl- 154(4 Suppl), 1–63. edge, attitudes, social and vocational function, Anderson, C., Reiss, D. J., & Hogarty, G. E. (1986). self-efficacy and self-esteem, and other indica- Schizophrenia and the family: A practitioner’s tors of quality of life and health. At the service guide to psychoeducation and management. New and community level, indicators should include York: Guilford Press. knowledge and attitudes among providers, and Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, documentation of health behaviors, service A. D., & Stickle, T. R. (1998). Empirically access and use, and cost-effectiveness (Dixon supported couple and family interventions for et al., 2000; Dixon et al., 2001; Lukens & marital distress and adult mental health Thorning, 1998). At the policy level there are problems. Journal of Consulting and Clinical two challenges: first, to assess readiness for Psychology, 66, 53–88.

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