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PSYCHOEDUCATION Introduction It is impossible to think of any treatment modality with out the active ingredients of educating patients and

d 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 patients 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 2. Delivered by professionals 3. Pts& caregivers participates 4. Longer d duration Diagnosis specific approach Patients well-being is primary goal

1. Community based 2. Anyone who has experience even pts can

3. Even those who do not have a sick person in their family can participate 4. Weeks to months 5. Not disorder specific 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 Inclusion criteria: based 1. Ability to perform 2. Diagnostic group task specific 2. Problem area 3. Usually comparable with individualize group d approach 3. Motivation to 4. Specific change problems /Problems Exclusion criteria 5. Unfit /unwilling 1. Marked for group PE incompatibility with group norms eg: Clinic based 2. Inability to PE for single tolerate group male settings 3. Incompatibility with one or other group members 4. Tendency to assume deviant role. eg: Group PE -BPAD

Inclusion criteria: Family and patients are in Ability to perform focus group task Patients wellProblem area being as well as family well compatible with group being is addressed Motivation to change 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 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 PEschizophrenia.

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 parents 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 selfesteem

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. 2. 3. 4. 5. 6. 7. 8. 9. Coordination and rehabilitation. Attend social and clinical needs. Medication management. Family- informed partner Compatible expectations Assess the strengths and limitations Sensitive to emotional distress. Explicit crisis plan. Improve communication.

10.Training in problem-solving techniques.

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

Modified BFM Broad-based Psychoeducation (McFarlane et al., 1993; (Hogarty et al., 1986, 1987; Leff et Tarrier et al. 1988, al. 1985) 1989)

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

1. Behavioral 1 Major aim is to techniques are increase stability of provided in home environment by multiple-family promoting effective groups that stress management. increase self-help 2 Employ myriad clinical and support strategies to educate 2. The primary family and to improve focus is on their coping skills (e.g., education, stress provision of multiple management, family support group, training in goal individual family setting and therapy, social skills achievement training) 3. Provided with 3 Individualized coping skill training broader sample of families and in Assessment of client and family in clinical settings terms of Strengths, weakness, goals Education- Communication skills training- -Problem-solving training

Assessment of client and family in terms of Strengths, weakness, goals - Education- Communication skills training- Problem-solving training

Assessment of client and family in terms of Strengths, weakness, goals - Education- Communication skills training-Problemsolving 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 o o

Separate illness from personality Role of educator, family partner, and trainer-coach 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. 2. 3. 4. 5. 6. Medication compliance Street Drug and Alcohol Use Life events Problems generated by other agencies Conflicts between family members 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 multifamily group

Practitioners act as educators Implementing family guidelines Reducing stigma Lowering expectations

1. Gradually increasing responsibilities 2. Monitored encouragement from family members 3. Establishing interfamily relationships 4. Focusing family interests outside family 5. Restoring family's natural social network

1. Validating group competency 2. More socializing, less problemsolving 3. Encouraging social contacts outside the group 4.Shifting role of clinicians 5.Converting to an advocacy group

Reducing negative intensity and exasperation

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 al2002 Not useful in chronic patients Reduced rehospitalization rate in medium duration of illness Brief 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 1995 FPE 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