Psychoeducation and Communication Skills Training
When clients come to Marriage & Family Therapists, they should understand that, although they may speak one-to-one with the therapist, the therapy itself involves others with whom the clients interact. Key to successful intervention is communication, and that simply cannot happen if everyone is not using the same language. This goes far beyond one’s native language or cultural expressions. Just like in physical medical treatment, for there to be optimal recovery in mental health, the patients need to understand what the professional diagnoses the problem to be and how to resolve it. The more severe the problem, the more important it is that all parties have a clear understanding of what is going on and how to most successfully treat it.
For all treatments, and for Chronic and Severe Mental Illness (CSMI) especially, if the members of the systems express emotions (EE), whether consciously or not, that are counterproductive to treatment, every effort to make improvements can easily be negated (Lee, Wang, Tang, Liu, & Bell, 2015). Psychoeducation including communication skills has been shown repeatedly to improve treatment outcomes for even addiction-related mental illnesses because the systems surrounding the patient are conscious of how their words and actions can be perceived by the patient.
Usefulness of Psychoeducational Approaches to Chronic and Severe Mental Illness
Research has shown that families of patients with CHMI, including Schizophrenia (Öksüz, Karaca, Özaltın, & Ateş, 2017) and depression, who express high levels of emotion prolong or even negate treatment between sessions. Whether real or perceived, how a patient feels their support systems feel about their issue directly impacts the success of treatment. Especially in cases of CSMI, families tend to be overinvolved and, consequently, overemotional about the situation. Although some studies have shown that overinvolved families can cause successful treatment because of perceived validation of importance by the patient, psychoeducation of these families leads to greater success particularly when higher levels of criticism and overprotectiveness are present (Öksüz et al., 2017).
When close families are presented with a chronic problem, they tend to stick together and can often forgo offers of help from outsiders. More often than not, family members are not already well informed about what caused the problem, what the symptoms are, and how best to treat it, so they may become even more insulated and can make bad choices for the patient. Psychoeducation resolves this problem. Instead of keeping the medical information to themselves, patients are taught to understand these concepts and are therefore able to make better, informed choices. Öksüz et al. (2017) reinforces the idea of early psychoeducation to prevent problems of misunderstanding entirely in cases of Schizophrenia. Psychoeducation does result in lower levels of Expressed Emotion, but it does not negate the positive traits of supportive families.
Indeed, for the caregivers of diagnosed Schizophrenics, Sadath, Muralidhar, Varambally, Gangadhar, & Jose (2017) demonstrate that psychoeducation reduces stress levels and occurrences of depression. Not many caregivers are professionals as well. Most are family members who have never experienced having to care for a loved one with a mental illness and are not emotionally equipped to sustain their own sense of well-being. Secondary trauma is common in these situations, but psychoeducation aids in recovery for the caregiver because they are then better equipped to handle what is so often a life-long obligation.
What emerged from research is the fact that psychoeducation does not resolve a CSMI, but it does seem to lessen the feelings of burden and helplessness among system members, and that does help in ongoing, life-long treatment and coping. It supplements direct treatment of the problem, whether the problem resolves or not. In other words, psychoeducation is useful in reducing the systemic results caused by the illness and that, in turn, affect the system outlook on treatment and recovery/maintenance. It certainly doesn’t seem to hurt. But considering the nature of psychoeducation, it may make sense that the treatment would be more effective for diagnoses that are less severe.
Principles of Psychoeducational Treatment Applicable to Other Diagnoses
Moskovich, et al, (2017) looked at the effectiveness of psychoeducation on parents of children with Anorexia Nervosa (AN) with high levels of EE. They applied Acceptance-based Separated Family Treatment (ASFT), which aims to teach system members to willingly examine their own negative thoughts and feelings to replace them with more effective, supportive behaviors. Treatment not only teaches behavior management skills but self-care as well.
Gumus, et al. (2015) looked at the effectiveness of psychoeducation on families and patients of Bipolar Disorder, wherein they provided information about medication effectiveness, symptoms, warning signs, communication skills and problem-solving. As one will discover in the next session, the results were generally favorable for the inclusion of psychoeducation. If these examples are generally what one would find in psychoeducation, it follows that inclusion of empowering systems through knowledge for any diagnosis would be beneficial. They say that knowledge is power. It could be power to do positive or negative things. But ignorance is not bliss when it comes to families who want their loved ones to recover from illness. In fact, ignorance can be damaging. Psychoeducation is the practice of translating the medical jargon into layman’s terms. It arms families with full understanding of what is actually happening and what they can do to help fix the problem. Like most therapy, psychoeducation is not easy for any member of the system. In this case, as it is in other therapies, it is meant to shed light on everything in shadow, including the negative behaviors of the system’s members that have caused, are causing, or are contributing to a lack of or slow recovery. Whether the problem is depression, anxiety, fear, or anger, educating the system just seems like a natural byproduct of good family therapy.
Effectiveness of Psychoeducational Treatments
There are many kinds of psychoeducational treatments. Basically, any kind of treatment that includes empowering patients and their families with foundational knowledge about the illness can be considered psychoeducation. Generally, these can include training in self-assertiveness, problem solving, and communication (Bäuml, Froböse, Kraemer, Rentrop, & Pitschel-Walz, 2006). Practitioners in Germany made Psychoeducation an entirely separate practice because of its effectiveness. German studies revealed significant reductions in hospital stays, for example.
In a study of the effect of family expressed emotion on heroine addicts, Lee et al. found that EE “interacts with depression and anxiety and may be linked to further relapse among heroin addicts,” (p. 43, 2015). The study did not find a definitive relationship between EE treatment and heroine addiction recovery, but it did show that higher levels of EE in families were related to higher levels of depression among addicts. Higher rates of depression did correlate with higher rates of relapse and lower rates of treatment retention.
In a follow-up study of Schizophrenic patients in Europe, the question was asked if early psychoeducation still had an impact on recovery of patients one year after treatment ended (MAGLIANO et al., 2005). They found that of 55 patients and their families, there remained significant signs of improvement of symptoms, social function, familial feeling of burden, and coping strategies.
A study in Spain (Casañas et al., 2015) examined the effectiveness of psychoeducation on patients suffering from depression who were considered “antidepressant-naiive,” or those who have not yet taken antidepressants. Using the Beck Depression Inventory (BDI), as many researchers apparently do for their studies, they found that after complete psychoeducation treatment 40% of patients in the intervention group were in remission compared to 12% of the control group.
It seems that the impact of psychoeducation on results is more dependent upon the enmeshment of the families and the level of Expressed Emotion that comes with it. If a therapist perceives obstacles in treatment via high EE, one would assume psychoeducation could reduce or eliminate it. But for families who are not bound and protective, psychoeducation may be a waste of time unless there is buy-in. If there is buy-in, the effect might be a more connected family.
References
Bäuml, J., Froböse, T., Kraemer, S., Rentrop, M., & Pitschel-Walz, G. (2006). Psychoeducation: A Basic Psychotherapeutic Intervention for Patients With Schizophrenia and Their Families. Schizophrenia Bulletin, 32(Suppl 1), S1–S9.
Casañas, R., Catalán, R., Penadés, R., Real, J., Valero, S., Muñoz, M. A., … Casas, M. (2015). Evaluation of the Effectiveness of a Psychoeducational Intervention in Treatment-Naïve Patients with Antidepressant Medication in Primary Care: A Randomized Controlled Trial [Research article].
Lee, C.-H., Wang, T.-J., Tang, H.-P., Liu, Y.-H., & Bell, J. (2015). Familial expressed emotion among heroin addicts in methadone maintenance treatment: Does it matter? Addictive Behaviors, 45, 39–44.
MAGLIANO, L., FIORILLO, A., FADDEN, G., GAIR, F., ECONOMOU, M., KALLERT, T., … MAJ, M. (2005). Effectiveness of a psychoeducational intervention for families of patients with schizophrenia: Preliminary results of a study funded by the European Commission. World Psychiatry, 4(1), 45–49.
Moskovich, A. A., Timko, C. A., Honeycutt, L. K., Zucker, N. L., & Merwin, R. M. (2017). Change in expressed emotion and treatment outcome in adolescent anorexia nervosa. Eating Disorders, 25(1), 80–91.
Öksüz, E., Karaca, S., Özaltın, G., & Ateş, M. A. (2017). The Effects of Psychoeducation on the Expressed Emotion and Family Functioning of the Family Members in First-Episode Schizophrenia. Community Mental Health Journal, 53(4), 464–473.
Sadath, A., Muralidhar, D., Varambally, S., Gangadhar, B. N., & Jose, J. P. (2017). Do stress and support matter for caring? The role of perceived stress and social support on expressed emotion of carers of persons with first episode psychosis. Asian Journal of Psychiatry, 25, 163–168.
