Psychoeducation: a Measure to Strengthen Psychiatric Treatment

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Psychoeducation: A Measure to Strengthen Psychiatric Treatment

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The user has requested enhancement of the downloaded file. APRIL 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 Review Article Psychoeducation: A Measure to Strengthen Psychiatric Treatment

Dipanjan Bhattacharjee*, Altul Kumar Rai***, Narendra Kumar Singh*, Pradeep Kumar*, Sanjay Kumar Munda**, Basudeb Das**,

*Department of Psychiatric Social Work,and **Psychiatry (CIP), Kanke, Ranchi-834006, Jharkhand, ***Institute of Human Behaviour & Allied Sciences (IHBAS), Dilshad Garden, Delhi-110095. Introduction improve. Psychoeducation is an educative method aimed Definitions of Psychoeducation to provide necessary information and training to The working group of ‘‘Psychoeducation of families with psychiatrically ill persons to work patients with schizophrenia’’ gave the following together with mental health professionals as part definition of psychoeducation: “The term psychoe- of an overall clinical treatment plan for their ill ducation comprises systemic, didactic psychothera- family members. Psychoeducation has been peutic interventions, which are adequate for emerged as an effective adjunctive treatment which informing patients and their relatives about the can significantly improve the level of understanding illness and its treatment, facilitating both an of people about mental disorders, ensuring active understanding and personally responsible handling participation of both patients and their caregivers of the illness and supporting those afflicted in in treatment as well as make psychiatric treatment coping with the disorder” 3. Later Bäuml et al4 acceptable to mentally ill people and their defined psychoeducation as: ‘systematic, structur- caregivers. Basic objectives of psychoeducation are: ed, didactic information on the illness and its providing knowledge about various facets of illness- treatment, and includes integrating emotional signs, symptoms, course, outcome and prognosis, aspects in order to enable patients – as well as dispelling misconceptions and unawareness, family members – to cope with the illness’. Barker5 helping people have knowledge regarding do’s and defined psychoeducation as the “process of teaching don’ts’ while rendering care to ill people or how to clients with mental illness and their family members interact or behave and communicate with ill people, about the nature of the illness, including its treatment options, side effects of medication and aetiology, progression, consequences, prognosis, other somatic treatments, helping people to track treatment and alternatives”. early signs of relapses of illness and last but not the least to increase the likelihood of mentally ill Time Line of Psychoeducation peoples re-entry into their home communities, with During the last half of 18th Century and early particular regard for their social and occupational part of 19th Century some philanthropists like functioning. In a nutshell Psychoeducation’s goal Johann Heinrich Pestalozzi (1746-1827) and Dr. is to offer education and therapeutic strategies to Samuel Gridley Howe (1801-1876) used educative improve the quality of life for the family while methods for providing therapeutic service and care decreasing the possibility of relapse for the patient1. to the physically and psychologically compromised It also has been described as a “systematic didactic- people. But before the onset of “Mental Hygiene psychotherapeutic intervention, designed to inform Movement” of early 20th Century and “Deinsti- patients and their relatives about the disorder and tutionalization Movement of 1950-60” there was to promote coping”2. By strengthening the coping no example of structured and organized psycho- skills, communication and problem solving abilities education. Psychoeducation came into the field of of the family, the well-being and adaptability of the psychiatry strongly after the appearance of individual and family members are expected to “Expressed Emotion” and “Family Burden Delhi Psychiatry Journal 2011; 14:(1) © Delhi Psychiatric Society 33 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 APRIL 2011

Concept” in connection to severe and chronic ii. family support, psychiatric disorder like schizophrenia. In true sense iii. crisis intervention and the concept of psychoeducation came into picture iv. problem solving skills training. through the writing of John E. Donley who wrote b) Family interventions should not be restricted an article namely “Psychotherapy and re-education” to patients whose families have been found to which was published in The Journal of Abnormal have high levels of ‘expressed emotion’. Psychology, came in the year 1911. Subsequently c) Family therapies based upon the premise that Brian E. Tomlinson wrote a book entitled as: “The family dysfunction has some aetiological role psychoeducational clinic” which was published by in schizophrenia should not be used. MacMillan Co in 1941. The popularization and Recommendations put forward by PORT do not development of the term psychoeducation into its prescribe one specific formula of family interven- current form can be attributed to the American tion. Rather, these recommendations ask for the researcher C.M. Anderson. She established this inclusion of those above-said components in any intervention as an adjunctive but effective treatment kind family of family intervention also PORT says of schizophrenia in 19804,6. that it is not necessary to apply family psychosocial intervention indiscriminately to all families with Models of Psychoeducation schizophrenia affected individuals. In families with Psychoeducation interventions offered to acute problems in all those aforesaid areas could family members of people with mental disorders be given those interventions along with other especially severe mental disorder have been conventional treatments8. Several different models developed with high degree of sophistication over of psychoeducation were developed time to time in the past 20 years. Psychoeducation has been an accordance with the needs of mentally ill people indispensible mode of adjunctive psychotherapy and their caregivers. Examples of few such models since expressed emotions were discovered as are development of family psychoeducation model potential responsible factors for relapses in involving single- and/or multiple-family groups; schizophrenia7. Since its inception psychoeducation mixed groups that include family members and has been showing lots of promise to ensure better patients; groups of varying duration ranging from prognosis and effectiveness of psychiatric nine months to more than five years; and groups interventions. Many models of psychoeducation that focus on patients and families at different have also been developed since then. The famous phases in the illness. The various psychoeducational Schizophrenia Patient Outcomes Research Team models can be categorised into four approaches. (PORT) developed treatment recommendations for Most models used the component from more than the care of persons with schizophrenia. The famous one approach but usually they have specific focus Schizophrenia Patient Outcomes Research Team on making concerned people aware about various (PORT) derived those recommendations after doing aspects of illness and treatment as well as educating an extensive review of the findings of previously people about their roles and responsibilities to done scientiûc research studies on schizophrenia. mentally ill people. These models can be Recommendations covered both psychosocial and summarized as9-12: psychopharmacologic treatments. The Schizophre- • Information model: The emphasis of this nia Patient Outcomes Research Team (PORT) gave model is to provide families the knowledge following three recommendations on family about psychiatric illness and its manage- psychosocial interventions8: ment. The aim of this approach is to a) Patients who have been having intensive improve the families’ awareness about the interaction with their families and living in illness and contribution to the management same household with family members should of the patient. be given a family psychosocial intervention • The skill training model: This model is which should continue for at least nine months directed at systematically developing speci- and should incorporate: fic behaviours so that family members can i. education about the illness, enhance their capability to assist the ill

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relatives and manage the illness more nisms that may buffer the vulnerable family effectively. member from the negative effects of • The supportive model: It is an approach environmental stresses and also family which generally utilizes support groups members can be provided knowledge about designed to engage the families of patient how to plan and implement of various tasks in sharing their feelings and experiences. essential for rehabilitation and aftercare of Here the main goal is to enhance and patient. The family therapy also attempts improve the emotional capacities of the to enhance coping skills of family members families to cope with the burden of caring through increasing the efficiency of family for their ill relatives. problem solving 9. • Comprehensive model: It is also called • Family Focussed Threatment (FFT): combination approach because it consists This approach of family based psychoe- of information, skill training and supportive ducation developed by David J. Miklowitz model. In the initial phase of this approach and MJ Goldstein14. This approach of members are given lectures about the psychoeducation is primarily developed for illness. They are to take part in multi-family the treatment of bipolar patients. This support group. In the final phase they have model has three modules; in first FFT to participate particularly as a member of module, psychoeducation is included and individual sessions with a mental health it is generally given in seven or more professional. sessions. During these sessions patients and • The Multiple Family Group Therapy relatives are to be told about the symptoms, Model (The MGFT Model): This model nature, causes, and treatment of bipolar of psychoeducation was developed by disorder. The clinicians during the sessions William McFarlane with the aims of engag- would educate the targeted people about the ing families in the rehabilitation and after biological and genetic underpinnings of care programmes of severe psychiatric bipolar from a vulnerability–stress diathe- illness like schizophrenia. This model sis perspective. Participants are to be acknowledges the essentially chronic educated to know the prodromal signs of nature of this disease and seeks to engage illness and relapsing episodes. The second families in the rehabilitation process by module (seven to 10 sessions), aims to help creating a long-term working partnership patients and caregivers to learn communi- with them and providing them with the cation skills for dealing with intrafamilial information needed to understand schiz- stress (active listening, requesting changes ophrenia. This model seeks to assist the in each others’ behavior, giving positive and patient and family in accommodating the negative feedback) and techniques like disease while developing social support role-playing/behavior-rehearsal format are systems for the reduction of confusing, generally used to teach these people about anxiety, and exhaustion in the patient’s communication related skills9,15. Finally, in family, while they learn adaptive strate- the third module (four to five sessions), gies13. participants are given a framework for • The Behavioural Family Management defining problems and how to develop as Model: This model of family intervention well as implement effective solutions to gives maximum importance to family and those problems. This approach also aims views family as the most effective and to instill problem-solving and coping skills efficient resource for community rehabilita- of the caregivers of these patients16. tion of severely ill mental patients. As per • Peer-to-Peer Psychoeducation App- this model healthy functioning of the roach: This approach was successfully mentally ill individual can be achieved applied in clinical setting by Rummel et al through instilling positive coping mecha- 17. The rationale of this approach is persons

who underwent same kind of experience popularization of deinstitutionalization, there has earlier can understand the problem of the been a surge in awareness of common people about people who have that problem now. Those the importance of the family for the care of persons people who had the problem earlier could with severe mental illnesses. Approximately 25% empathize the problem of people who have and 60% individuals with severe mental illnesses recently develop that problem in much live at home, and many more are in active contact better manner than those people who never with relatives19. Now community based treatment had that. In peer-to-peer psychoeducation and care is in the helm of treatment and rehabilita- programme mentally ill persons are given tion of mentally ill people in almost everywhere in the access to mix with the people who had the world. Unfortunately, in many occasions the same problem earlier but they important stakeholders of patient care like key recuperated from that problem. These caregivers and to some extent community people people can motivate the patients up to have often been uninformed as well as undertrained considerable extent and provide them a new to manage such a complex situation, i.e., providing ray of hope. Rummel et al17 proposed a 5 care to individuals with chronic mental illness. But step psychoeducation programme which many evidences are there which have been quite can be delivered through peer educators categorical in showing the effectiveness of (peer moderators) who happen to the ex- psychoeducation in strengthening the psychiatric patients. treatments by ensuring active cooperation of key caregivers with the treating team in treatment and Psychoeducation: An Indispensible Adjunct to adherence of patients to prescriptions and Modern Psychiatric Treatment suggestions of treatment20. Few researchers tried The recent trend in psychiatric treatment is to to do comparison among different approaches e.g., provide a combinational treatment which includes combination approaches (comprising of pharmac- pharmacotherapy/somatic therapy and various otherapy + psychotherapy + psychoeducative modes of psychotherapy. The combined approach intervention at family level or pharmacotherapy + has been proved to be more efficacious in targeting psychotehrapy) and monotherapy (either pharmac- all areas of patient’s illness and functionality quite otherapy only or psychotherapy only). Hogarty et suitably than any single therapy-based approach. al study21 compared four manualized treatment In combinational approach psychoeducation conditions: personal relapse-prevention therapy, invariably or even inadvertently comes into picture family psychoeducation, personal relapse-prevent- as an adjunctive psychotherapy9. Psychoeducation ion therapy plus family psychoeducation, and to family members has been emerged as an general supportive therapy in a total of 97 persons important prerequisite to modern psychiatric diagnosed with schizophrenia and who live with treatment and rehabilitation, since through their key care givers at their respective homes. psychoeducation many problematic areas related to Authors had found that personal therapy had a patient care and compliance with the treatment can positive effect on adverse outcomes among patients be successfully addressed. A large chunk of who lived with family. However, personal therapy mentally ill people either live with or maintain increased the rate of psychotic relapse for patients contact with their core family members. But living independent of family21. In China Xiang et families often become critical to their mentally ill al22 accomplished a 4-month family intervention on members and do not show the desired level of 69 people with schizophrenia and 8 persons with cordiality and supportiveness to their ill member affective psychoses. These authors randomly what they should have been. In many case families assigned these 77 patients into two treatment show antagonism to their ill members owing to conditions: a) family intervention plus ignorance and unawareness about their therapeutic pharmacotherapy, and b) pharmacotherapy alone. roles in long term care of these people and how to The group who had received family intervention keep a balance between family functions and plus pharmacotherapy had significant positive optimal level of patient care18. In fact, after the changes which were not found in other group who

36 Delhi Psychiatry Journal 2011; 14:(1) © Delhi Psychiatric Society APRIL 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 received pharmacotherapy only. The positive therapy modiûed for cocaine dependence; or (4) changes were characterized by enhancement in group drug counseling plus individual drug treatment compliance level, low level of neglect and counseling, which was based on the disease- abuse of the patients by family members; and oriented, 12-step model of addiction. Authors marked improvement in mental status of the observed that the group received drug counseling patients, improvement in work functioning, and plus individual drug counseling had the best decreased disruptive behavior of the patients. In substance use outcomes26. Kaminer et al initiated a bipolar disorder psychoeducation based adjunctive study on adolescents with dual diagnosis of a treatment like family focused treatment (FFT), psychiatric disorder and substance addiction with Interpersonal Social Rhythm Therapy (IPSRT), the objective of comparing the efficacy of cognitive- psychoeducation in group and individual format behavioral treatment and psychoeducation. These were examined time to time by various researchers authors randomly assigned 88 adolescents with to find their suitability in treatment package23. aforesaid diagnosis (dual diagnosis of a psychiatric Patients with bipolar disorders do often have many disorder and substance addiction) to either psychological and behavioural comorbidities and cognitive-behavioral treatment or psychoeducation. presence of those conditions would create lots of The psychoeducation package comprised of both obstacles to effective treatment. In those conditions didactic and videotaped presentations about the extra amount of efforts are warranted from the multidimensional problems associated with treating team and multiplication of treatment substance addiction. These authors found that at modules are required. Presence of psychiatric the end of study period (i.e., 9 months) there were comorbidity like personality disorder is a predictor no signiûcant differences between these two of poor outcome for bipolar patients and has been groups27. In another study Martin et al28 compared associated with increased suicide risk, higher the effectiveness of two closed-group conditions, chances of having mixed and depressed features in i.e. a) the group used psychoeducation approach the course of illness, development of residual focused on providing knowledge about substances symptoms, poor response to treatment and low and its negative consequences and the other Group; treatment adherence24. In those cases adding a group b) “pre-recovery” group, was based on the stages- based psychoeducational programme may be a of-change model described by Prochaska et al29. For useful intervention24. In substance addiction the purpose of the study Martin et al28 sequentially psychoeducational interventions can also be assigned 118 addicted individuals into these two incorporated in the treatment processes comprised groups. The pre-recovery group was designed to of regular and well established addiction treatment. facilitate the change process. In the second group, It can be beneficial to both caregivers and patients members (addicted individuals) were told to to know about some specific elements related to identify their life’s problem areas and to discuss aetiology, predisposition, maintenance and relapses few issues like a) the impact of substance addiction of addiction to substance addiction. Example of one on their lives; b) efforts made by them to curb large scale study was the National Institute on Drug substance addiction so far; c) why they should Abuse Collaborative Cocaine Treatment Study remain abstinent for longer time and d) finally their where authors randomly assigned 487 cocaine- personal treatment plans. At the end of study authors dependent individuals to one of four conditions: (1) found that patients rated the psychoeducation group group drug counseling alone, which aimed to as more helpful, they preferred to remain with the educate patients about stages of recovery, treatment condition (attached with the group) for encouraged 12-step participation, and provided longer period and most importantly there were no support for abstinence and alternatives to use; (2) differences in the outcome of substance addiction25, group drug counseling plus cognitive therapy, which 28. gave emphasis on identification and challenge the Conclusion maladaptive thoughts associated with cocaine addiction; (3) group drug counseling along with Psychoeducation has become an indispensible supportive-expressive therapy, a psychodynamic adjunctive psychotherapy in the field of mental

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