PSYCHOEDUCATION

Introduction

It is impossible to think of any treatment modality with out the active ingredients of educating patients and their families.

Psychoeducation (PE) has been around for a long time- a popular tool, often used prior to, or in conjunction with, family therapy.

It has become integral part of all treatment modalities in our day-to-day clinical practice.

Used less frequently in a formalized way

Historical background

No one person "invented" the psychoeducation -psychoeducation evolved from different, albeit related, philosophies and strategies for working with troubled minds.

Psychoeducation finds its earliest roots in the thinking of humanitarians such as Itard (1775-1838) and others

Some psychoeducators trace their philosophical roots back to Freud, - the tree has become much larger and more elaborate over the past fifty years.

For many years, psychiatry did not educate its patients - little information available to guide development of the patient’s education.

Literature appeared mostly as articles in nursing journals, such as the American Journal of Nursing.

Attained prominence in the first part of the 20th century- community mental helath programme.

Lack of knowledge and skills needed for managing a serious psychiatric disorder such as schizophrenia, bipolar disorder or severe depression.

Community mental health movement, consumer advocacy, the family education movement etc stimulated the research on PE.

Conceptual issues and controversies

PE shares common boundaries with counseling and psychotherapy, at least in aims and goals but demarcations are clear.

Definition of PE

PE as per current clinical understanding & practice:

Disorder specific – given by clinical expert to patient &/ or his family to learn knowledge and skills and better long-term management of issues related to illness as well as psychosocial adjustment - a part of the overall treatment plan and includes communication treatment plan.

The term PE used for medical and surgical conditions which requires psychosocial adaptation.

Hatfield (1988) the value of the psycho part of psychoeducation and suggested that education is just as informative and less confusing. What is Psychoeducation

Educational approach:

1. Education - as a process of inducing “progressive or desirable changes in a person as result of teaching and study” (Wolberg),.

2. Intellectual development & emotional growth of the of children aroused hopes in utilizing educational approaches toward reshaping attitudes, altering values, reorganizing feelings and refashioning beehaviour

Counseling v/s psycoeducation

1. Addresses a particular area of difficulty-educational /vocational / behavioural

2. Need not be related to illness and treatment plan.

3. Expert is selected and consulted based on the felt need.

4. Clients decide, based on the best options.

Psychotherapy v/s psychoeducation

Family members often included

Total plan of management explained in PE– in psychotherapy patient moves along & himself discovers the problems

Aim of PE is to inform regarding illness, methods required to treat it and not that these methods of psychoeducation lead to relief of symptoms.

Psychoeducation prepare the patient to take action.

Psychodeducation v/s family education

Psychoeducation Family education

1. Clinic based 1. Community based

2. Delivered by professionals2. Anyone who has experience even pts can

3. Pts& caregivers participates 3. Even those who do not have a sick person in their family can participate

4. Longer d duration 4. Weeks to months

Diagnosis specific approach 5. Not disorder specific

Patients well-being is primary goal

6. Family well-being is primary goal.

Psychoeducation

Psychoeducation is a specific form of education - helps persons with mental illness &/or their family members

Can be used in any type of mental illness - some say is essential in all cases.

Opportunity is given to describe their own symptoms & experiences- enables to formulate a cohesive treatment plan.

Information provided nature of the illness, medication, and alleviating and aggravating factors. 

Assessing and learning strategies to deal with mental illness and its effects.

What it is not

Psychoeducation is not a treatment but a part of an overall treatment plan. (McFarlane however recent use of problem solving, skills training etc, psychoeducation is becoming itself as treatment

Why use Psychoeducation

More a person understand his illness and how it affects his own live and that of others, the more control that person has over his illness.

What distinguishes psychoeducation?

Psychoeducator understands the importance of the patients’ illness/symptom early experience etc., but does not dwell on it.

Behaviors are dealt with in the here and now, and no attempt to trace them back to their early origins of psychotherapy

Mature, realistic stance with the patients / family in an empathic, focused and pragmatic manner.

The common components of psychoedcuation

General Objectives of the psychoeducation program

1. To promote physical, psychological and emotional well-being of people with mental illness and their carers

2. To enhance therapeutic alliance between health care provider and patients, care givers and families

Procedure of psychoeducation

1. Psychoeducation is conducted on need basis.2. Most of the time the psychiatrist is responsible in conducting it.3. There is no standardized or structured program- attempts being made

But the resent literature says psychoeducation can be delivered even in community, by patients & their family members or trained paraprofessionals

Patient focused PE

Group PE Family PE Multiple group family PE

1. Usually clinic based

2. Diagnostic specific

3. Usually individualized approach

4. Specific problems /Problems

5. Unfit /unwilling for group PE

eg: Clinic based PE for single male

Inclusion criteria:

1. Ability to perform group task

2. Problem area comparable with group

3. Motivation to change

Exclusion criteria

1. Marked incompatibility with group norms

2. Inability to tolerate group settings

3. Incompatibility with one or other group members

4. Tendency to assume deviant role.

eg: Group PE -BPAD

Family and patients are in focus

Patient’s well-being as well as family well being is addressed

Support to family

Enhance their capacity to cope

Basic concepts:

Sever MI patients live in their family of origin; family is active partner in health care of patients.

eg;SF PE

Schizophrenia

Inclusion criteria:

Ability to perform group task

Problem area compatible with group

Motivation to change

Exclusion criteria

Marked incompatibility with group norms

Inability to tolerate group settings

Incompatibility with one or other group members

Tendency to assume deviant role

eg; Multiple Family PE- schizophrenia.

Psychoeducation in some psychiatric disorders

Psychoeducation in schizophrenia

Most studies evaluating the effects of the family interventions have found that the psychoeducational programs for families produce dramatic reductions in the number and duration of acute episodes of illness among their ill relatives as well as improved adjustment for family members.

Expressed Emotion (EE)

High levels of criticism, hostility, over involvement by family were significantly related to relapse of ill relative

Family Burden

25% to 66% of Pts with schizophrenia hospitalized return to their families parents

Feelings of loss, guilt, failure- “ When I am gone…”

Spouses

Feelings of loss of companionship and intimacy, resentment/, /Role strains/View their mate as another child in need of supervision

Siblings

Feelings of loss/Resentment /Concern about future care giving

Children

Genetic risk / Impaired parenting / Embarrassment, stigma/ Assuming parent’s role/Poor school performance, suicidal thoughts/Social withdrawal

Factors Contributing to Family Burden

Caring older relative is more burdensome Patients with behavioral problems cause more burden Provision of day-to-day care for the ill Stigma surrounding mental illness leads isolation, lowered self-

esteem

Gratification of Care giving

Sense of personal growth as a result of coping with mental illness

Increased compassion and understanding of persons with mental illness

Learning new coping skills,

Developing positive family relationships

Family Needs

Information on mental illness Suggestions for coping Emotional support Information on community resources Substitute care to relieve family Treatment coordination Social support

Principles in working with family members:

1. Coordination and rehabilitation. 2. Attend social and clinical needs. 3. Medication management. 4. Family- informed partner5. Compatible expectations 6. Assess the strengths and limitations 7. Sensitive to emotional distress. 8. Explicit crisis plan. 9. Improve communication.

10.Training in problem-solving techniques.

Behavioral Family Management (BFM)(Falloon et al. 1985, 1987)

Modified BFM (McFarlane et al., 1993; Tarrier et al. 1988, 1989)

Broad-based Psychoeducation (Hogarty et al., 1986, 1987; Leff et al. 1985)

1. Based on behavioral family therapy model and social learning theory

2. Provided to entire family (including client)

3. Home-based approach to maximize generalization of skills learned

Assessment of client and family in terms of

Strengths, weakness, goals - Education- - Communication skills training- -Problem-solving training

1. Behavioral techniques are provided in multiple-family groups that increase self-help and support

2. The primary focus is on education, stress management, training in goal setting and achievement

3. Provided with broader sample of families and in clinical settings

Assessment of client and family in terms of

Strengths, weakness, goals - Education- - Communication skills training- -Problem-solving training

1 Major aim is to increase stability of home environment by promoting effective stress management.

2 Employ myriad clinical strategies to educate family and to improve their coping skills (e.g., provision of multiple family support group, individual family therapy, social skills training)

3 Individualized coping skill training

Assessment of client and family in terms of

Strengths, weakness, goals - Education- - Communication skills training- -Problem-solving training

Psychoeducation in multifamily pychoeducation group (MFPE) (Mc Farlane et al )

Stages of a psychoeducational multifamily group

Joining stage- family and patient separately and lasts 3-6 weeks. Then the family moves to stage 2 - educational workshop Finally, the family and patient move to stage 3 - ongoing multifamily group

where they attend the group for 1-4 years.

Important steps in MFPE (-Mc Farlane )

1) Starting a FPE group

Find a compatible co-facilitator Attend a training and follow manual Explore your own motivation and enthusiasm Discuss with your supervisor, you will need support

2) Components of groups

5-6 families with similar diagnoses Meetings every other week for a minimum of 9 months, monthly after 12-18

months Families, consumers, and practitioners become partners Problem-solving format

3) Role of FPE practitioner

o Separate illness from personality o Role of educator, family partner, and trainer-coach o Use the problem solving method to deal with illness-related behaviors

4) Creating an optimal social environment

Keep It Simple -Go Slow -Keep It Cool -Give `Em Space -Set Limits

Ignore What you Can't Change Lower Expectations- at least temporarily Follow Doctor's Orders No Street Drugs or Alcohol Pick Up on Early Warning Signs Solve Problems Step By Step

6) Psycho educational Workshop

6 hours of illness education

Relaxed, friendly atmosphere Co-leaders act as hosts Questions and interactions encouraged

5) Elements of education

History and epidemiology Biology of schizophrenia Treatment: effects and side effects Family emotional reactions Family behavioral reactions Guidelines for coping and management Socializing

7) Problem solving

Control affect and arousal Compensate for information-processing difficulties in patients and some relatives Be organized and systematic Problem that is agreed upon by all family members Validate all positions Undertake a step-wise or sequential solution Succeed and overcome failure

A hierarchy for problem solving

1. Medication compliance 2. Street Drug and Alcohol Use 3. Life events 4. Problems generated by other agencies 5. Conflicts between family members

6. Conflicts with family guidelines

Brainstorming solutions

All members can contribute All suggestions are welcome No suggestion is analyzed or critiqued during brainstorming Suggestions are limited to 10 - 12 ideas

The person with the identified problem chooses 1 - 2 suggestions to try

Phases and Interventions in FPE/PMFGs

Year One: Relapse Prevention Year Two: Rehabilitation Year Three: Network Formation

Engaging individual families Exploration of precipitants

1. Review of prodromal symptoms/signs

2. Reactions of family to illness

3. Coping strategies

4. Social supports

5. Contract for treatment

6. Preparation for multi-family group

Practitioners act as educators

Implementing family guidelines

Reducing stigma Lowering expectations

Reducing negative intensity and exasperation

1. Gradually increasing responsibilities

2. Monitored encouragement from family members

3. Establishing inter-family relationships

4. Focusing family interests outside family

5. Restoring family's natural social network

1. Validating group competency

2. More socializing, less problem-solving

3. Encouraging social contacts outside the group

4.Shifting role of clinicians

5.Converting to an advocacy group

SCARF model

PE is an integral part of family intervention (family therapy)

Psychoeducation:

Structured family education programme

At least secondary school education,

Social worker, psychologist and psychiatrist

7-10 families - active participation

Didactic and interactinary with the active use of audio- visual aids

Content of the programme:

Signs and symptoms of schizophrenia

Etiology, and brief overview of management issue

Introduction of rehabilitation.

Sensitize the families to participate in more in depth interventions

Non-structured family education programme- for illiterate families

1. Discussion with families either singly or in groups

2. Use of audio visual and electronic media aids

3. Use of flip charts etc

Barriers / limitations

Patient and/or family participation Rapid turnover of previously trained staff Staff burnout, unrelated to adoption process Insufficient administrative support Requires lengthy, though low intensity, work

Psychoeducation in affective disorders

Focus is on reduction of relapse rate

Reduction interepisode symptoms

Increasing the drug compliance

Dealing with socio environmental stressors

Dealing with expressed emotions (Milkowitz et al )

PE programme for families of affectively ill children (Brent et al)

Symptoms / course/ outcome

Medications/ high risk for suicide etc,

Psychoeducation in substance abuse

Addiction/dependency/ high-risk behaviours

Coping / abstinence / motivation enhancement / relapse prevention

Efficacy of family psychoeducation

Social functioning (Falloon et al. 1985)

Client-self report: significantly greater overall social adjustment was reported by family management group in areas of leisure activity and family relationship over 9 months

Efficacy studies of Psychoeducation

Schizophrenia

Feldmann R et al2002Not useful in chronic patientsReduced rehospitalization rate in medium duration of illnessBrief multiple family psychoeducation program did not reduce the number or duration of admissions of the young people.

Affective disorders

David et al 2003, Combining FPE with pharmacotherapy enhances the post episode symptomatic adjustment and drug adherence of bipolar patients

Colom Fet al 2003

The action of PE goes beyond compliance enhancement viz,Lifestyle regularity and healthy habits,

Early detection of prodromal signs Prompt drug intervention, Treatment compliance.

Honig A et al 1995FPE lower the expressed emotions and reduce the rehospitalization rates

Srinivasan J et al 2003 Women were more likely to endorse their depressive disorder as related to a biological abnormality.

Psychoeducation Indian scene

Sekar et al 1988: development of psychoeducation materials.

SCARF (Chennai): experiences in India

Prema et al 1998 PE is beneficial in rehabilitation programmes (schizophrenia), Psy Nurse is useful in psychoeducation programmes.

Prema et al 1998:PE is effective in reducing the distress.

Direction for Future Research

Timing of family psychoeducation Process through which family psychoeducation works Includes multiple outcome measures (e.g., cost benefit, satisfaction)

Conclusion

Conceptual differences - family therapy

Need to develop manuals for PE Need to sanitize the families as well as professionals Need to regulate “others” from diluting the psychoeducations