Imagine this scenario. Your partner – called, let’s say “Chris” – has just had a period of acting extremely erratically. First there were the weeks of being so high, so full of seemingly impossible ideas, and talking so fast and furiously that you thought drugs might be involved. Unspecified charges starting turning up on the credit cards, until several of the cards were “maxxed” out; Chris wasn’t fazed at all. The expansive, sometimes irritated and “I can do anything” mood was accompanied by very little time in bed. You even wondered how to get hold of some of what Chris was on! But inevitably, the high gave way to one of the worst lows you have ever seen someone close to you go through; Chris began to spend life on the beige couch in your lounge, depressed, fatigued, and feeling totally worthless. The effortless flow of ideas now became a severely diminished capacity for thinking and concentrating, and the former sleep schedule of three hours a night now stretched to nine or ten – on a good day. In short, Chris’ mood had swung from one extreme to another.

Concerned, you got Chris to the doctor, and then to the psychologist, for evaluation. Many measures were administered, there were exploratory sessions, and then finally today you both went to the psychologist’s office to find out what has been going on. Sadly, you left the office with the name of a disorder, but not much more insight. The psychologist – in a tone that you thought was unnecessarily cold and clinical – said that Chris had Bipolar disorder. Chris was issued with scripts for medications and you were both given a huge pile of small-print, very clinically-oriented literature to read. When you asked for a brief explanation, the psychologist said, “Just read what I’ve given you. It will explain everything; it is important that we offer you this psychoeducation.”

Disheartened, you trudged home with your partner, only to reflect that, if being thrown a pile of medical literature and told to go away and read it constitutes psychoeducation, you are definitely not a fan of that practice. It was no help at all! Chris looks even more crumpled with despair. Could your experience truly be called “psychoeducation”? We would say, “No, that’s not it at all.”

Psychoeducation has been termed the combining of “the empowerment of the affected” with “scientifically-founded treatment expertise” in as efficient a manner as possible (Bauml, Frobose, Kraemer, Rentrop, & Pitschel-Walz, 2006/2014). A common understanding is that psychoeducation “refers to the education offered to people with a mental health condition” (Wikipedia, 2014).

More broadly, it is also referred to as “an important component of any psychotherapy program as well as any visit you have to the doctor. . . . [It] is education about a certain situation or condition that causes psychological stress” (myVMC, 2014). The author of the second definition is at pains to point out that a person can receive psychoeducation for physical as well as mental health conditions: for example, breast cancer. Cancer generally causes huge psychological stress in its victims, so psychoeducation is useful as one way of combating stress.

Frances Colom (2011), referring to psychoeducation as “psychological interventions for mood disorders”, states that these can be divided into “skilled” and “simple”. Psychoeducation belongs to the latter group: “a simple and illness-focused therapy with prophylactic efficacy in all major mood disorders” (Colom, 2011). Other writers argue that psychoeducation is not a treatment in itself, but – in clinical settings at least – the first step of the overall treatment plan (Reyes, 2010).

The goals

Psychoeducation occurs in a range of contexts and may be conducted by a variety of professionals, each with a differing emphasis. In general, however, four broad goals direct most psychoeducation efforts:

1. Information transfer (as when clients/patients and their families and carers learn about symptoms, causes, and treatment concepts)
2. Emotional discharge (a goal served as the patient/client or family ventilates frustrations during the sessions or exchanges with similar others their experiences concerning the problem)
3. Support of a medication or other treatment, as cooperation grows between professional and client/patient and adherence and compliance issues diminish
4. Assistance toward self-help (that is, training in aspects such as prompt recognition of crisis situations and knowledge of what steps should be taken) (Wikipedia, 2014).

A special education teacher blogged that the rationale behind a psychoeducational approach is that, given a clear understanding of their condition and self-knowledge about their individual strengths, family resources, and coping skills, clients are more relaxed and better equipped to deal with their problem(s), which contributes to their emotional wellbeing (Reyes, 2010). The core message is simply that education has a role in emotional and behavioural change. With an improved understanding of the causes and effects of the problem, psychoeducation can broaden a client’s perception and interpretation of the problem; the additional insight positively influences the person’s emotions and behaviour. More positive emotions and behaviour, in turn, lead to an enhanced sense of self-efficacy. More solid self-efficacy leads to better self-control: important for many with serious illness at either physical or psychological levels, as clients often feel helpless and out of control (Reyes, 2010).

Later we will discuss the different formats in which psychoeducation can be offered; here we can say that one format, family psychoeducation, has aimed for – and been successful at achieving – a reduction of relapse rates and symptom levels and improving the social participation of people living with severe and persistent psychotic disorders (Hayes, Harvey, & Farhall, 2013). The goal of family psychoeducation, as with other formats, is to improve knowledge and coping skills in families and clients, enabling them to work together more effectively to address the challenges of living with illness, especially mental illness.

You might be curious as to how psychoeducation came to be so widely embraced as a “good thing to do” along with the medical or psychological treatment. As a discerning professional, you also need to know how effective it is. We turn to that now.

The history and research findings

The concept of psychoeducation, although not the word, was noted in an article by John Donley entitled “Psychotherapy and re-education” in the Journal of Abnormal Psychology in 1911. 30 years later in 1941, Brian Tomlinson introduced the word to the medical community with the title of his book, The psychoeducational clinic, published in New York. The first French use of the cognate term is in a thesis published in 1962: La stabilite du comportement. American researcher C.M. Anderson popularised the term in 1980 with her work on the treatment of schizophrenia. Her research focused on educating family members about the symptoms and process of the disorder, and on how family members could improve communication and relationships between themselves. Anderson also included stress management techniques (Wikipedia, 2014).

Early psychoeducation programs grouped several therapeutic elements together, delivering them within a larger family therapy intervention. Patients and their families were given a preliminary briefing on the illness of the patient in the hopes that, developing a fundamental understanding of the illness, they would be willing to commit to more long-term involvement (Bauml et al, 2006/2014).

The format of family psychoeducation (as opposed to that for the client/patient alone or in other settings) originated with stress-diathesis models of mental illness, which emphasise the interaction between an individual’s diathesis, or vulnerability, and the environment in the development or worsening of mental illness. Such models posit that the diathesis, often dormant, can take the form of genetic, psychological, biological, or situational factors; a large range of individual difference exists between persons in their vulnerability to the development of disorder. The greater the vulnerability and/or the greater the stressors in the person’s environment, the greater is the likelihood of the individual manifesting the latent tendency (Wikipedia, 2014).

Research in the 1960s into expressed emotion had found that environments in which there were hostile or critical comments and where family members had emotional over-involvement were sources of high stress for people living with psychosis; such situations were associated with increased relapse (Burbach & Stanbridge, 1998, in Hayes et al, 2013). Thus both patients and their families welcomed the development of behavioural and cognitive techniques in emergent therapies such as Rational Emotive Therapy (RET) and Cognitive Behavioural Therapy (CBT) during the 1970s and 1980s. The use of these began to reduce stress as families learned more about mental illness and practised more effective communication and self-care. Conditions which psychoeducation helped included Bipolar disorder, major depressive disorder, anorexia nervosa, and – more recently – Post-Traumatic Stress Disorder (PTSD) (Hayes et al, 2013).

Since the mid-1980s, in Europe at least, psychoeducation has evolved into an independent therapeutic program focusing on effective, teaching-oriented communication of key information within a cognitive-behavioural approach. The theme of empowerment and coping through understanding was manifest early on as attendance at basic psychoeducational sessions came to be regarded as an “obligatory-exercise” program. Subsequent “voluntary-exercise” programs (such as individual behavioural therapy, assertiveness training, problem-solving sessions, or communication training) could be and often were added on (Bauml et al, 2006/2014).

Similarly in the school setting, psychoeducation has been around since the 1970s, with current models blending developmental, cognitive, and learning psychology theories. In classrooms, the emphasis is on behaviour management methods that teachers can use to modify troubled behaviours. Classroom psychoeducation helps behaviourally-disordered students with the social and emotional skills that are apparently lacking. Topics of “emotional literacy” are forefront; popular themes are resilience, decision-making, social problem-solving, and self-management of emotions: all ideally suited to classroom delivery (Reyes, 2010).

Finally, psychoeducation is deemed to be an important aspect of trauma therapy. The rationale in this application is that many survivors of interpersonal violence are victimised in the context of overwhelming emotion, forced dissociation of attention, and – sometimes – early cognitive development at the time of trauma. All of these factors, plus the traumatic presence of a powerful figure distorting objective reality – work to reduce the accuracy and coherence of the survivor’s understanding of the traumatic event. Psychoeducation in this context has come to be understood as a means of providing accurate information on the nature of trauma and its effects and assistance with integrating into the survivor’s perspective both the new information and any implications thereby generated (Briere, 2006).

Numerous authors refer to evidence that psychoeducation is consistently effective at what it purports to do (Pharoah, Mari, Rathbone, & Wong, 2010; Bauml et al, 2006/2014; Colom, 2011; Hayes et al, 2013). A review of over 50 randomised, controlled trials involving almost 2000 clients showed that family psychoeducation is effective for improving the mental health and functioning of both clients and their families in many cultures (Pharoah et al, 2010). It was shown to decrease the frequency and severity of relapse for clients by 20 to 50 percent. Improvements were shown in mental state, family relationships, client capacity to adhere to medication, effective functioning in employment, and capacity for social engagement.

The authors noted that, although outcomes for carers have been studied less, they were positive in four main areas: decreased burden, lowered psychological stress, increased capacity to cope, and enhanced social connection (Pharoah et al, 2010). Similarly, a randomised study conducted at multiple centres in Munich showed a significant reduction in re-hospitalisation rates – from 58 percent to 41 percent – over a two year period. The intermittent days in hospital over this period reduced from 78 to 39 on average (Bauml et al, 2006/2014).

Colom (2011) reports the results of a randomised, controlled trial on the efficacy of a structured group psychoeducation intervention involving clients with Bipolar disorder. At five-year follow-up, the psychoeducation group showed a longer time to recurrence. This group also had fewer recurrences than the non-psychoeducation group. In addition, the psychoeducation group spent much less time being acutely ill, which was attributed to the striking differences accounting for time spent in depression (364 days versus 399 days); the number of days depressed is reported to be a strong predictor of recurrences according to the STEP-BD data (Perlis, Ostacher, Patel, Marangell, Zhang, & Wisniewski, 2006).

Still on the theme of results with Bipolar disorder, earlier research showed that even a simple intervention consisting of merely seven to twelve sessions of training on early warning sign detection was linked with a significant increase in time to first manic relapse (65 weeks versus 17 weeks). There was also a decrease in the number of manic episodes over 18 months. Moreover, social functioning and employment over 18 months were significantly improved (Perry, Tarrier, Morris, McCarthy, & Limb, 1999). Colom (2011) has noted that psychoeducation seems to be so widely used for mood disorders because it maps well onto the medical model of illness by being a clinically focused, common sense-based, and straightforwardly delivered intervention.

Finally, a systematic review or meta-analysis of psychoeducation as a component in the treatment of depression was undertaken in 2012. Searching the medical data bases of LILACS, PsychINFO, PubMed, SCOPUS, and ISI Web of Knowledge under the terms “psychoeducation”, “psychoeducational intervention”, and “depression” (with no restriction on publishing dates), researchers located 15 studies which met criteria for inclusion. 13 of these evaluated the effectiveness of psychoeducation for patients with depression, one evaluated psychoeducational interventions for patients’ families and patients’ responses, and the fifteenth evaluated psychoeducational interventions for patients’ families and families’ responses. Findings suggested that increased knowledge about depression and its treatment is associated with better prognosis in depression, as well as with the reduction of the psychosocial burden for the family (Tursi, Baes, Camacho, Tofoli, & Juruena, 2013).

In referring to clients, families, and students receiving psychoeducation, we’ve alluded to the ways in which it is delivered. As the format through which the program is offered impacts largely on its potential for success, this aspect merits closer examination.

The formats of psychoeducation

We’ve summarised research results for psychoeducation in clinical settings and referred to how it is used in school settings. Psychoeducation is a flexible intervention, able to be implemented in a variety of different formats and settings. Which format is chosen depends on the illness or disorder, the developmental age of the client whose condition is the subject of the program, and the individual needs of the client/patient and others in his/her life.

Psychoeducation can be individually implemented, (peer) group-based, parent- or family-based, or set up for roles such as caregivers, teachers, and friends. Advocates of psychoeducation are adamant that psychoeducation is for anyone experiencing psychological hardship or stress due to a condition, and that it is such individuals’ right to have information about their disorder. Thus, no matter what state a person’s mind or emotions may be in, that person should receive some psychoeducation, as appropriate.

Usually the person with the disorder/illness is present at the sessions, but in some situations (as when the client/patient is too young, developmentally delayed, or too ill to attend) a program may be offered to the people who deal with the individual on a day-to-day basis, such as family members, caregivers, teachers, and friends, without including the cared-for person. In this instance, however, the person with the condition should be offered a parallel program at a suitable (but obviously different) level. With that caveat, what are the main formats?

Individual psychoeducation

Does your client wish to maximise information transference in a manner that is uniquely suited to his or her circumstance? Is the person threatened by group situations, feeling anxious at the thought? Or perhaps the person is an extremely private individual and wishes to retain privacy and confidentiality. In any of these cases, individual sessions may be indicated, and the psychoeducational content can be woven into the fabric of the sessions. Some clients have an opposite preference.

Group psychoeducation

If you have ever had a client trapped in a sense of shame about their condition, the group format – somewhat surprisingly – might be just the right way to help the person face into their condition in a supportive environment. Groups are known to be less intimidating for some clients than one-on-one sessions with their mental health practitioner. The “Really Embarrassing Questions” about the condition are often asked by others in the group, so clients can frequently get much of the information that they need without having to ask for themselves. Moreover, clients are able to benefit from others’ experience, as well as share about their own. The sense of not being alone and having group support are key elements in making the group a positive experience, which reduces stress and stigma, increases motivation to manage the illness/disorder, and enhances self-efficacy.

In schools, psychoeducation can be a prophylactic measure, initiated to appropriate groups before they may develop certain conditions, so that they will not develop them. Topics relevant to this application of psychoeducation are those such as eating disorders and body image, anger management and bullying, and teenage pregnancy. Similarly, children diagnosed with diseases such as diabetes or epilepsy may benefit by having classmates and others attend psychoeducational sessions to learn about the disease and its management. Sessions for this reason have been known to reduce stigma and increase acceptance of the student (myVMC, 2014).

Psychoeducation for parents and family

The high preponderance of research with families receiving psychoeducation points to the importance of this format. Simply put, an illness or disorder affects not only the individual diagnosed with the problem, but also, all those who are in his or her life sphere: most centrally, the person’s family. Thus, any information, discussion, or activities which can help family members to understand and cope with the condition, better understand the person suffering from it, and – given the added burden of stress – help family members to get along with one another, is a valued addition to the pool of therapeutic interventions applied.

Sometimes multiple families are involved at once, accruing similar benefits to group work, in that most frequently asked questions tend to come up in the sessions without every family having to think of every question to ask. As with group psychoeducation, the participants can share tips and strategies with one another for managing the condition and the life that that must flow around it (myVMC, 2014).

Psychoeducation for caregivers and friends

In some cases, especially with conditions of mental illness, your client may not have many family members around, but the person still needs support. Alternatively, the person may have a fulltime caregiver who could support them better with more knowledge about the disorder/disease. Some programs, therefore, are developed around educating people in these roles (myVMC, 2014).

© 2014 Mental Health Academy

This article was adapted from Mental Health Academy’s upcoming “Psychoeducation for Clients” CPD course. To learn more, visit www.mentalhealthacademy.com.au.

References

• Bauml, J., Frobose, T., Kraemer, S., Rentrop, M., & Pitschel-Walz, G. (2006/2014). Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin. October, 2006; 32(Suppl 1): S1-S9 doi: 10.1093/schbul/sbl017. PMCID: PMC2683741. Retrieved on 29 April, 2014, from: hyperlink.
• Briere. (2006). Psychoeducation. Retrieved on 29 April, 2014, from: hyperlink.
• Colom, F., Vieta, E., Sanchez-Moreno, J., Palomino-Otiniano, R., Reinares, M., Goikolea, J.M., Benabarre, A., & Martinez-Aran. (2009). Group psychoeducation for stabilised Bipolar disorders: 5-year outcome of a randomised clinical trial. British Journal of Psychiatry (2009) 194:260-265 doi: 10.1192/bjp.bp.107.040485.Retrieved on 30 April, 2014 from: hyperlink.
• Hayes, L., Harvey, C., & Farhall, J. (2013). Family psychoeducation for the treatment of psychosis. Australian Psychological Society. InPsych: April, 2013. Retrieved on 29 April, 2014, from: hyperlink.
• myVMC. (2014). What is psychoeducation? Virtual Medical Centre. Retrieved on 29 April, 2014, from: hyperlink.
• Perlis R.H., Ostacher M.J., Patel J.K., Marangell L.B., Zhang, H., Wisniewski, S.R., et al. (2006). Predictors of recurrence in Bipolar disorder: Primary outcomes from the Systematic Treatment Enhancement Program for Bipolar disorder (STEP-BD). American Journal of Psychiatry 2006; 163: 217– 24.
• Perry, A., Tarrier, N., Morris, R., McCarthy, E., & Limb, K. (1999). Randomised controlled trial of efficacy of teaching patients with Bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal, 1999; 318: 149– 53.
• Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family intervention for schizophrenia: 2010 update. Cochrane Database of Systematic Reviews 2006(4).
• Reyes, C. (2010). What is psycho-education? Psycho-educational teacher for students with behavioral issues. Retrieved on 30 April, 2014, from: hyperlink.
• Tursi, M.F., Baes, C.V., Camacho, F.R., Tofoli, S.M., Juruena, M.F. (2013). Effectiveness of psychoeducation for depression: A systematic review. Australia New Zealand Journal of Psychiatry. (2013) Nov: 47 (11): 1019-31. Doi: 10.1177/0004867413491154. Epub 2013 June 5. Retrieved on 29 April, 2014, from: hyperlink.
• Wikipedia. (2014). Psychoeducation. Wikimedia Foundation, Inc. Retrieved on 30 April, 2014, from: hyperlink.