Psychoeducation: A Measure to Strengthen Psychiatric Treatment

Transcription

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 , Jharkhand, ***Institute of Human Behaviour & Allied Sciences (IHBAS), Dilshad Garden, Delhi Introduction Psychoeducation is an educative method aimed to provide necessary information and training to families with psychiatrically ill persons to work together with mental health professionals as part of an overall clinical treatment plan for their ill family members. Psychoeducation has been emerged as an effective adjunctive treatment which can significantly improve the level of understanding of people about mental disorders, ensuring active participation of both patients and their caregivers in treatment as well as make psychiatric treatment acceptable to mentally ill people and their caregivers. Basic objectives of psychoeducation are: providing knowledge about various facets of illnesssigns, symptoms, course, outcome and prognosis, dispelling misconceptions and unawareness, helping people have knowledge regarding do s and don ts while rendering care to ill people or how to interact or behave and communicate with ill people, treatment options, side effects of medication and other somatic treatments, helping people to track early signs of relapses of illness and last but not the least to increase the likelihood of mentally ill peoples re-entry into their home communities, with particular regard for their social and occupational functioning. In a nutshell Psychoeducation s goal is to offer education and therapeutic strategies to improve the quality of life for the family while decreasing the possibility of relapse for the patient 1. It also has been described as a systematic didacticpsychotherapeutic intervention, designed to inform patients and their relatives about the disorder and to promote coping 2. By strengthening the coping skills, communication and problem solving abilities of the family, the well-being and adaptability of the individual and family members are expected to improve. Definitions of Psychoeducation The working group of Psychoeducation of patients with schizophrenia gave the following definition of psychoeducation: The term psychoeducation comprises systemic, didactic psychotherapeutic interventions, which are adequate for informing patients and their relatives about the illness and its treatment, facilitating both an understanding and personally responsible handling of the illness and supporting those afflicted in coping with the disorder 3. Later Bäuml et al 4 defined psychoeducation as: systematic, structured, didactic information on the illness and its treatment, and includes integrating emotional aspects in order to enable patients as well as family members to cope with the illness. Barker 5 defined psychoeducation as the process of teaching clients with mental illness and their family members about the nature of the illness, including its aetiology, progression, consequences, prognosis, treatment and alternatives. Time Line of Psychoeducation During the last half of 18th Century and early part of 19th Century some philanthropists like Johann Heinrich Pestalozzi ( ) and Dr. Samuel Gridley Howe ( ) used educative methods for providing therapeutic service and care to the physically and psychologically compromised people. But before the onset of Mental Hygiene Movement of early 20th Century and Deinstitutionalization Movement of there was no example of structured and organized psychoeducation. Psychoeducation came into the field of psychiatry strongly after the appearance of Expressed Emotion and Family Burden Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society 33

2 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 APRIL 2011 Concept in connection to severe and chronic psychiatric disorder like schizophrenia. In true sense the concept of psychoeducation came into picture through the writing of John E. Donley who wrote an article namely Psychotherapy and re-education which was published in The Journal of Abnormal Psychology, came in the year Subsequently Brian E. Tomlinson wrote a book entitled as: The psychoeducational clinic which was published by MacMillan Co in The popularization and development of the term psychoeducation into its current form can be attributed to the American researcher C.M. Anderson. She established this intervention as an adjunctive but effective treatment of schizophrenia in ,6. Models of Psychoeducation Psychoeducation interventions offered to family members of people with mental disorders especially severe mental disorder have been developed with high degree of sophistication over the past 20 years. Psychoeducation has been an indispensible mode of adjunctive psychotherapy since expressed emotions were discovered as potential responsible factors for relapses in schizophrenia 7. Since its inception psychoeducation has been showing lots of promise to ensure better prognosis and effectiveness of psychiatric interventions. Many models of psychoeducation have also been developed since then. The famous Schizophrenia Patient Outcomes Research Team (PORT) developed treatment recommendations for the care of persons with schizophrenia. The famous Schizophrenia Patient Outcomes Research Team (PORT) derived those recommendations after doing an extensive review of the findings of previously done scientiûc research studies on schizophrenia. Recommendations covered both psychosocial and psychopharmacologic treatments. The Schizophrenia Patient Outcomes Research Team (PORT) gave following three recommendations on family psychosocial interventions 8 : a) Patients who have been having intensive interaction with their families and living in same household with family members should be given a family psychosocial intervention which should continue for at least nine months and should incorporate: i. education about the illness, ii. family support, iii. crisis intervention and iv. problem solving skills training. b) Family interventions should not be restricted to patients whose families have been found to have high levels of expressed emotion. c) Family therapies based upon the premise that family dysfunction has some aetiological role in schizophrenia should not be used. Recommendations put forward by PORT do not prescribe one specific formula of family intervention. Rather, these recommendations ask for the inclusion of those above-said components in any kind family of family intervention also PORT says that it is not necessary to apply family psychosocial intervention indiscriminately to all families with schizophrenia affected individuals. In families with acute problems in all those aforesaid areas could be given those interventions along with other conventional treatments 8. Several different models of psychoeducation were developed time to time in accordance with the needs of mentally ill people and their caregivers. Examples of few such models are development of family psychoeducation model involving single- and/or multiple-family groups; mixed groups that include family members and patients; groups of varying duration ranging from nine months to more than five years; and groups that focus on patients and families at different phases in the illness. The various psychoeducational models can be categorised into four approaches. Most models used the component from more than one approach but usually they have specific focus on making concerned people aware about various aspects of illness and treatment as well as educating people about their roles and responsibilities to mentally ill people. These models can be summarized as 9-12 : Information model: The emphasis of this model is to provide families the knowledge about psychiatric illness and its management. The aim of this approach is to improve the families awareness about the illness and contribution to the management of the patient. The skill training model: This model is directed at systematically developing specific behaviours so that family members can enhance their capability to assist the ill 34 Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

3 relatives and manage the illness more effectively. The supportive model: It is an approach which generally utilizes support groups designed to engage the families of patient in sharing their feelings and experiences. Here the main goal is to enhance and improve the emotional capacities of the families to cope with the burden of caring for their ill relatives. Comprehensive model: It is also called combination approach because it consists of information, skill training and supportive model. In the initial phase of this approach members are given lectures about the illness. They are to take part in multi-family support group. In the final phase they have to participate particularly as a member of individual sessions with a mental health professional. The Multiple Family Group Therapy Model (The MGFT Model): This model of psychoeducation was developed by William McFarlane with the aims of engaging families in the rehabilitation and after care programmes of severe psychiatric illness like schizophrenia. This model acknowledges the essentially chronic nature of this disease and seeks to engage families in the rehabilitation process by creating a long-term working partnership with them and providing them with the information needed to understand schizophrenia. This model seeks to assist the patient and family in accommodating the disease while developing social support systems for the reduction of confusing, anxiety, and exhaustion in the patient s family, while they learn adaptive strategies 13. The Behavioural Family Management Model: This model of family intervention gives maximum importance to family and views family as the most effective and efficient resource for community rehabilitation of severely ill mental patients. As per this model healthy functioning of the mentally ill individual can be achieved through instilling positive coping mechanisms that may buffer the vulnerable family member from the negative effects of environmental stresses and also family members can be provided knowledge about how to plan and implement of various tasks essential for rehabilitation and aftercare of patient. The family therapy also attempts to enhance coping skills of family members through increasing the efficiency of family problem solving 9. Family Focussed Threatment (FFT): This approach of family based psychoeducation developed by David J. Miklowitz and MJ Goldstein 14. This approach of psychoeducation is primarily developed for the treatment of bipolar patients. This model has three modules; in first FFT module, psychoeducation is included and it is generally given in seven or more sessions. During these sessions patients and relatives are to be told about the symptoms, nature, causes, and treatment of bipolar disorder. The clinicians during the sessions would educate the targeted people about the biological and genetic underpinnings of bipolar from a vulnerability stress diathesis perspective. Participants are to be educated to know the prodromal signs of illness and relapsing episodes. The second module (seven to 10 sessions), aims to help patients and caregivers to learn communication skills for dealing with intrafamilial stress (active listening, requesting changes in each others behavior, giving positive and negative feedback) and techniques like role-playing/behavior-rehearsal format are generally used to teach these people about communication related skills 9,15. Finally, in the third module (four to five sessions), participants are given a framework for defining problems and how to develop as well as implement effective solutions to those problems. This approach also aims to instill problem-solving and coping skills of the caregivers of these patients 16. Peer-to-Peer Psychoeducation Approach: This approach was successfully applied in clinical setting by Rummel et al 17. The rationale of this approach is persons Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society 35

4 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 APRIL 2011 who underwent same kind of experience earlier can understand the problem of the people who have that problem now. Those people who had the problem earlier could empathize the problem of people who have recently develop that problem in much better manner than those people who never had that. In peer-to-peer psychoeducation programme mentally ill persons are given the access to mix with the people who had the same problem earlier but they recuperated from that problem. These people can motivate the patients up to considerable extent and provide them a new ray of hope. Rummel et al 17 proposed a 5 step psychoeducation programme which can be delivered through peer educators (peer moderators) who happen to the expatients. Psychoeducation: An Indispensible Adjunct to Modern Psychiatric Treatment The recent trend in psychiatric treatment is to provide a combinational treatment which includes pharmacotherapy/somatic therapy and various modes of psychotherapy. The combined approach has been proved to be more efficacious in targeting all areas of patient s illness and functionality quite suitably than any single therapy-based approach. In combinational approach psychoeducation invariably or even inadvertently comes into picture as an adjunctive psychotherapy 9. Psychoeducation to family members has been emerged as an important prerequisite to modern psychiatric treatment and rehabilitation, since thr ough psychoeducation many problematic areas related to patient care and compliance with the treatment can be successfully addressed. A large chunk of mentally ill people either live with or maintain contact with their core family members. But families often become critical to their mentally ill members and do not show the desired level of cordiality and supportiveness to their ill member what they should have been. In many case families show antagonism to their ill members owing to ignorance and unawareness about their therapeutic roles in long term care of these people and how to keep a balance between family functions and optimal level of patient care 18. In fact, after the popularization of deinstitutionalization, there has been a surge in awareness of common people about the importance of the family for the care of persons with severe mental illnesses. Approximately 25% and 60% individuals with severe mental illnesses live at home, and many more are in active contact with relatives 19. Now community based treatment and care is in the helm of treatment and rehabilitation of mentally ill people in almost everywhere in the world. Unfortunately, in many occasions important stakeholders of patient care like key caregivers and to some extent community people have often been uninformed as well as undertrained to manage such a complex situation, i.e., providing care to individuals with chronic mental illness. But many evidences are there which have been quite categorical in showing the effectiveness of psychoeducation in strengthening the psychiatric treatments by ensuring active cooperation of key caregivers with the treating team in treatment and adherence of patients to prescr iptions and suggestions of treatment 20. Few researchers tried to do comparison among different approaches e.g., combination approaches (comprising of pharmacotherapy + psychotherapy + psychoeducative intervention at family level or pharmacotherapy + psychotehrapy) and monotherapy (either pharmacotherapy only or psychotherapy only). Hogarty et al study 21 compared four manualized treatment conditions: personal relapse-prevention therapy, family psychoeducation, personal relapse-prevention therapy plus family psychoeducation, and general supportive therapy in a total of 97 persons diagnosed with schizophrenia and who live with their key care givers at their respective homes. Authors had found that personal therapy had a positive effect on adverse outcomes among patients who lived with family. However, personal therapy increased the rate of psychotic relapse for patients living independent of family 21. In China Xiang et al 22 accomplished a 4-month family intervention on 69 people with schizophrenia and 8 persons with affective psychoses. These authors randomly assigned these 77 patients into two treatment conditions: a) family intervention plus pharmacotherapy, and b) pharmacotherapy alone. The group who had received family intervention plus pharmacotherapy had significant positive changes which were not found in other group who 36 Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

5 received pharmacotherapy only. The positive changes were characterized by enhancement in treatment compliance level, low level of neglect and abuse of the patients by family members; and marked improvement in mental status of the patients, improvement in work functioning, and decreased disruptive behavior of the patients. In bipolar disorder psychoeducation based adjunctive treatment like family focused treatment (FFT), Interpersonal Social Rhythm Therapy (IPSRT), psychoeducation in group and individual format were examined time to time by various researchers to find their suitability in treatment package 23. Patients with bipolar disorders do often have many psychological and behavioural comorbidities and presence of those conditions would create lots of obstacles to effective treatment. In those conditions extra amount of efforts are warranted from the treating team and multiplication of treatment modules are required. Presence of psychiatric comorbidity like personality disorder is a predictor of poor outcome for bipolar patients and has been associated with increased suicide risk, higher chances of having mixed and depressed features in the course of illness, development of residual symptoms, poor response to treatment and low treatment adherence 24. In those cases adding a group based psychoeducational programme may be a useful intervention 24. In substance addiction psychoeducational interventions can also be incorporated in the treatment processes comprised of regular and well established addiction treatment. It can be beneficial to both caregivers and patients to know about some specific elements related to aetiology, predisposition, maintenance and relapses of addiction to substance addiction. Example of one large scale study was the National Institute on Drug Abuse Collaborative Cocaine Treatment Study where authors randomly assigned 487 cocainedependent individuals to one of four conditions: (1) group drug counseling alone, which aimed to educate patients about stages of recovery, encouraged 12-step participation, and provided support for abstinence and alternatives to use; (2) group drug counseling plus cognitive therapy, which gave emphasis on identification and challenge the maladaptive thoughts associated with cocaine addiction; (3) group drug counseling along with supportive-expressive therapy, a psychodynamic therapy modiûed for cocaine dependence; or (4) group drug counseling plus individual drug counseling, which was based on the diseaseoriented, 12-step model of addiction. Authors observed that the group received drug counseling plus individual drug counseling had the best substance use outcomes 26. Kaminer et al initiated a study on adolescents with dual diagnosis of a psychiatric disorder and substance addiction with the objective of comparing the efficacy of cognitivebehavioral treatment and psychoeducation. These authors randomly assigned 88 adolescents with aforesaid diagnosis (dual diagnosis of a psychiatric disorder and substance addiction) to either cognitive-behavioral treatment or psychoeducation. The psychoeducation package comprised of both didactic and videotaped presentations about the multidimensional problems associated with substance addiction. These authors found that at the end of study period (i.e., 9 months) there were no signiûcant differences between these two groups 27. In another study Martin et al 28 compared the effectiveness of two closed-group conditions, i.e. a) the group used psychoeducation approach focused on providing knowledge about substances and its negative consequences and the other Group; b) pre-recovery group, was based on the stagesof-change model described by Prochaska et al 29. For the purpose of the study Martin et al 28 sequentially assigned 118 addicted individuals into these two groups. The pre-recovery group was designed to facilitate the change process. In the second group, members (addicted individuals) were told to identify their life s problem areas and to discuss few issues like a) the impact of substance addiction on their lives; b) efforts made by them to curb substance addiction so far; c) why they should remain abstinent for longer time and d) finally their personal treatment plans. At the end of study authors found that patients rated the psychoeducation group as more helpful, they preferred to remain with the treatment condition (attached with the group) for longer period and most importantly there were no differences in the outcome of substance addiction 25, 28. Conclusion Psychoeducation has become an indispensible adjunctive psychotherapy in the field of mental Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society 37

6 DELHI PSYCHIATRY JOURNAL Vol. 14 No.1 APRIL 2011 health. There are several evidences which have shown the effectiveness of this therapy. Optimal care to individuals with chronic debilitating mental illness has to be multidimensional in nature and should incorporate all kinds of therapeutic services to address every aspects of illness. This is to be done because of the multifaceted character of psychiatric disorders. The stakeholders in psychiatric care like key caregivers, friends, peer-groups and community people should have optimal level of knowledge about psychiatric disorders and their treatment to avert negative events like development of negative attitude to patients in the forms of stigmatization, stereotypy, expressed emotions and social alienation. At the same time psychoeducation can also be initiated to draw the attention of caregivers and other acquaintances of mentally ill persons to remain cooperative and compliant to treating team and their suggestions. But it should be kept in mind that psychoeduca-tion has to be individualized or tailor-made for each patient or each family unit. Every psychoeduca-tional model cannot be applied over all family units or individuals indiscriminately. Additionally, without considering few factors like illness related, socio-demographic, socio-cultural and family factors psyhcoeducation cannot be successful. References: 1. Solomon P. Moving from psychoeducation for families of adults with serious mental illness. Psychiatr Serv 1996; 47 (12) : Lincoln TM, Wilhelm K, Nestoriuc Y. Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: A meta-analysis. Schizophr Res, 2007; 96 (1-3) : Ba uml J, Pitschel-Walz G. Psychoedukation bei schizophrenen Erkrankungen. Stuttgart, Germany: Schattauer; Article in German. As cited in: J Ba uml, T Frobo se, S Kraemer, M. Rentrop, and G. Pitschel-Walz. Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophr Bull 2006; 32 (1) : S1-S9. 4. Ba uml J, Frobo se T, Kraemer S, Rentrop M, Pitschel-Walz G. Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophr Bull 2006; 32(1) : S1-S9. 5. Barker RL. The Social Work Dictionary. NASW Press, Washington D.C., Hogarty GE, Ander son CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia: II. Twoyear effects of a controlled study on relapse and adjustment. Arch Gen Psychiatry 1991; 48 : Dixon L, Adams C, Hucksted A. Update on family psychoeducation for schizophrenia. Schizophr Bull 2000; 26(l) : Dixon L. Providing services to families of persons with schizophrenia: Present and future. Journal Mental Health Policy Eco 1999; 2 : Falloon IRH, Boyd JL, McGill CW, Williamson M, et al. Family management in the prevention of morbidity of schizophrenia. Arch Gen Psychiatry 1985; 42 : Goldstein MJ, Miklowitz DJ. The effectiveness of psychoeducational family therapy in the treatment of schizophrenic disorders. J Marital Fam Ther 1995; 21 : Goldstein MJ, Rea MM, Miklowitz DJ. Family factors related to the course and outcome of bipolar disorder. In: Mundt C, Goldstein MJ, Hahlweg K, Fiedler P, editors. Interpersonal Factors in the Origin and Course of Affective Disorders. London: 1996; pp Hogarty GE, Anderson CM, Reiss DJ, et al Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, I. One-year effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry 1986; 43 : McFarlane WR, Lukens E, Link B, et al: Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry 1995; 52 : Miklowitz DJ, Goldstein MJ. Behavioral family treatment for patients with bipolar affective disorder. Behav Modif 1990; 14 : Liberman RP, Mueser KT, Wallace CJ, Social skills training for schizophrenic individuals at risk for relapse. Am Psychiatry 1986; 143 : 38 Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

7 Miklowitz DJ, Simoneau TL, George EL, et al Family-focused treatment of bipolar disorder: 1 year effects of a psychoeducational program in conjunction with pharmacotherapy. Biol Psychiatry 2000; 48 : Rummel CB, Hansen W, Helbig A. et al Peerto-peer psychoeducation in schizophrenia: a new approach. J Clin Psychiatry 2005; 66 : Lefley HP. Family Psychoeducation for Serious Mental Illness. Oxford University Press, New York, USA, Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disor der in hospitalized severelymentally ill psychiatric patients: Prevalence, correlates, and subgroups. Schizophrenia Bull 2000; 26 : McGill CW, Falloon IRH, Boyd JL. Family educational intervention in the treatment of schizophrenia. Hosp Comm Psychiatry 1983; 34 (10) : Hogarty GE, Kornblith SJ, Greenwald D. et al. Three-year trials of personal therapy among schizophrenic patients living with or independent of family: I. Description of study and effects on relapse rates. Am J Psychiatry 1997; 154 : Xiang MG, Ran MS, Li SG. A controlled evaluation of psychoeducational family intervention in a rural Chinese community. Br J Psychiatry 1994; 165 : Rouget BW, Aubrey JM. Efficacy of psychoeducational approaches on bipolar disorders: A review of the literature. J Affect Disorders 2007; 98 : Colom F, Vieta E, Sa nchez-moreno J, et al Psychoeducation in bipolar patients with comorbid personality disorders. Bipolar Disord 2004; 6 : Weiss RD, Jafee WB, De Menil VP, et al Group Therapy for Substance Use Disorders: What Do We Know? Harv Rev Psychiatry 2004; 12 : Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 1999; 56 : Kaminer Y, Burleson JA, Goldberger R. Cognitive-behavioral coping skills and psychoeducation therapies for adolescent substance abuse. J Nerv Ment Dis 2002; 190 : Martin K, Giannandrea P, Rogers B, Johnson J. Group intervention with pre-recovery patients. J Subst Abuse Treat 1996; 13 : Prochaska J, DiClemente C, Norcross J. In search of how people change: Applications to addictions. Am Psychol 1992; 47 : Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society 39