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 mental health 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 schizophrenia 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, & 206 Brief Treatment and Crisis Intervention / 4:3 Fall 2004 Psychoeducation as Evidence-Based Practice 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 anxiety 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 psychosis 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