Many different interventions for
people with mental health disorders fit under the banner of
psychosocial educational interventions. These interventions seek to
bestow therapeutic, cognitive and sociability benefits through
education, goal setting, skill teaching, challenging thinking patterns,
and social interaction. This review investigates the theories behind
psychosocial educational interventions and finds them to be mostly
based on psychoeducation theory. The results of a variety of
psychosocial educational interventions are described and it was found
that such interventions can bring significant benefits to those
suffering from mental health disorders. Details are provided on the
important components in the practical delivery of psychosocial
educational interventions to enable beneficial results. The findings of
this review provide support for the use and further expansion of
psychosocial educational interventions for those with mental health
disorders. It is essential that psychosocial educational provision has
long term funding to enable it to be embedded, and to make it
sustainable.
Keywords: psychosocial
interventions, psychoeducation, education, mental health disorders
Introduction
The increasing emphasis on education for those with mental health
problems is partially due to the consumer movement with its advocacy
for an individual’s rights and empowerment (Landsverk & Kane 1998).
Psychoeducation covers a fundamental right of individuals to be
informed about his or her illness (Colom & Lam 2005). Authier
(1977) described psychoeductaion as a therapeutic approach that does
not focus on abnormality diagnosis, prescription, therapy, or cure, but
on goal setting, skill teaching, satisfaction, and goal achievement.
Furthermore, Colom & Lam stated that psychoeducation focuses on
compliance enhancement, early identification of prodromal signs, the
importance of life-style regularity, exploring individuals' health
beliefs and illness-awareness, and enabling the individual to
understand the complex relationship between symptoms, personality,
interpersonal environment, and medication side-effects. Psychoeductaion
is employed in many countries throughout the world, for example, the
UK, Denmark, USA, France, Poland, Australia, South Africa, and Norway.
There are various psychosocial educational interventions many of which
incorporate psychoeducational theories and principles. Particular
psychosocial educational interventions have included topics such as
research skills, legal issues and stress management (Greenberg, Fine,
Cohen & Larsen 1988, cited in Hayes & Gantt 1992). To date
there have been no comprehensive literature reviews of psychosocial
educational interventions and the present literature review seeks to
fill this gap. Specifically this literature review will consider the
theories behind psychoeducation, the benefits that psychosocial
educational interventions can provide people with mental health
disorders, the mechanisms involved, and the specific practical aspects
of psychosocial educational intervention programmes that provide any
beneficial effects.
Discussion
The theory behind psychoeducation
Morse (2004) explained that the theory behind psychoeducation is based
upon individual psychology; a holistic approach to understanding what
it means to be human. There are three strands embodied in individual
psychology. Firstly, dynamic psychology, which is the study of
emotional aspects, for example: motivation, purpose, fears, hopes,
goals, and perceptions of self. Secondly, how we learn and acquire new
knowledge and skills. Thirdly, developmental psychology, which
incorporates biological substrata, organic factors, and individually
unique maturational processes. In addition to these three strands,
Morse stated that participant social interactions are considered to be
crucial in the delivery of psychoeducation. Furthermore, Wood,
Brendtro, Fecser & Nichols (1999) stated the importance of
cognitive psychology in psychoeductaion, as it involve challenging
maladaptive thinking processes and suggesting alternative adaptive
patterns of thinking. Wood et al. described the theoretical perspective
of psychoeductaion as integrated, holistic, multicultural, multimodal,
functional, systemic, comprehensive, and functional. This inclusive,
adaptive and flexible theoretical perspective underpins many different
psychosocial educational interventions and has been applied in a
variety of forms and situations, and to a variety of different mental
disorders.
Benefits of psychosocial educational interventions
Mowbray & Megivern (1999) conducted research on the Michigan
Supported Education Intervention Project (MSEIP) for individuals with
mental health problems. Through qualitative data analysis they found
that the delivery of education in a group setting, that utilised
problem solving and role modelling, resulted in increased feelings of
empowerment. The study employed two intervention models and a control
group. One intervention was a classroom model based on a programme by
Unger, Danley, Kohn, & Hutchinson (1987, cited in Mowbray &
Megivern 1999) which utilised an academic support curriculum with small
group exercises and experiential learning; the topics covered included
managing the academic environment, stress management, and developing
career choices. The other intervention was a group support model that
offered the same topics but it employed consumer driven structured
group activities. Mowbray & Megivern found that both group and
classroom models significantly increased quality of life, self-esteem,
social adjustment, and further college vocational training
participation. They also found that participation in the group and
classroom interventions provided an increase in the use of specific
problem-solving strategies and improvements in a measure of optimal
goal setting. These results are very positive but their possible
generalisability is limited due to the fact the study was based solely
in and around Detroit, USA.
A Canadian study by Michalak, Yatham, Wan & Lam’s (2005) focused on
providing psychoeducation for individuals suffering from bipolar
disorder (BD). There were five aims of the programme; to help patients
identify the signs and symptoms of BD and to enhance knowledge about
illness course and relapse risk factors; to raise awareness of the
impact of BD on psychological, cognitive, physical, emotional, and
social functioning; to improve knowledge of pharmacologic treatment
modalities for BD and common side effects; to provide guidelines for
increased medication effectiveness and safety; and to provide cognitive
strategies for coping with BD. Through utilising a psychoeducation
intervention to achieve these aims they found that the participants had
significantly improved quality of life in terms of physical functioning
and general life satisfaction. Despite this study not utilising a
control group or controlling for changes in medication it adds to
previous research supporting the use of psychoeducation for BD
sufferers. Additional support also comes form a Spanish based control
group study by Colom et al. (2005). In this study participants took
part in an educational programme that taught recurrence identification
and improved life-style regularity in a group setting. Colom et al.
found that the programme was successful in improving illness awareness
and treatment adherence at the 6, 18 and 24 month follow up points.
There has also been research into psychosocial educational
interventions involving participants with major depressive disorder.
Dowrick et al.’s (2000) study assigned individuals living in the
community who were suffering from major depressive disorder to either a
problem solving course, a course on the prevention of depression, or to
a control group. They found that both the intervention courses resulted
in a reduction in the number of participants meeting a diagnosis of
depression, a reduction in depressive symptoms, and improved subjective
functioning. At the study’s 12 month follow up, Dowrick et al. found a
slight advantage for the problem solving programme over the course on
prevention of depression in reducing depressive symptoms. It possibly
the case that the problem solving skills acquired allowed participants
to cope with the continuing and changing demands in their lives in the
longer term. To counter a lack of significant effects for both
intervention strategies at the 12 month follow up Dowrick, et al.
recommended booster sessions. This study’s results have good
generalisability to major depressive disorder sufferers in various
European countries as the study employed participants from urban and
rural communities in Finland, Republic of Ireland, Norway, Spain, and
the United Kingdom.
Klausner et al. (1998) also studied depressed individuals, in this case
non-hospitalised participants suffering from late-life depression in
New York, US. The study utilized a psychoeducation intervention largely
based on Snyder’s (1994, cited in Klausner et al.1998) goal-focused
model of hope. This intervention model employed individualized goal
formulation, psychoeducation, and skills training in the areas of
anxiety management, cognitive restructuring, individualized behavioural
assignments, and the utilization of past success to guide achievement.
They found that this intervention resulted in a significant reduction
in depressive symptoms. They also found positive improvements in
measures of hope, hopelessness, anxiety, and social functioning. The
authors stated the limitations of their study as being a relatively
small participant group and the need for further research to determine
if these positive results can be repeated in other age and mental
disorder groups.
As well as studies involving participants with affective disorders
there has been a great deal of research conducted into psychosocial
educational interventions for those suffering from symptoms of
schizophrenia. In their literature review Ascher-Svanum & Whitesel
(1999, p. 297) found that individuals suffering from schizophrenia who
had taken part in an educational intervention gained benefits that
included: “improved compliance with the medication regimen, lower
relapse rate, longer participation in aftercare programs, improved
social functioning and quality of life, decreased negative symptoms,
improved insight into illness, improved skills acquisition, improved
attitudes toward medication intake, and a better understanding of
mental illness.” In their US based randomised control study
Ascher-Svanum & Whitesel (1999) delivered an educational programme
for people diagnosed with schizophrenia based on Ascher-Svanum &
Krause’s (1991, cited in Ascher-Svanum & Whitesel 1999) manual. The
educational intervention included topics on diagnosis, prevalence,
course, causes, prognosis, medication management, non-medical
treatments, stress factors, community resources, substance abuse, and
legal issues. They found that there were significant improvements in
knowledge about schizophrenia and illness insight, and a significant
decrease in negative cognitions about medication intake. More recently,
Hogarty et al. (2004) conducted a US based two year randomised control
trial into cognition and behaviour. Symptomatically stable outpatients
who met a diagnosis of schizophrenia or schizoaffective disorder were
given enriched supportive therapy (EST). EST fosters illness management
through applied cognitive coping strategies, stress management, social
cognition strategies, skills training, and education. They found that
EST can have positive effects on neurocognition, cognitive style,
social cognition, and social adjustment. However, the researchers
stated that Cognitive Enhancement Therapy (CET) had a greater effect in
reducing cognitive deficits in their participants than EST.
In addition to affective and psychotic disorder suffers, psychosocial
educational interventions have also been employed with a group of PTSD
suffers in the US (Gray, Ellahai & Frueh 2004) and a group with
cognitive deficiencies in the Netherlands (Commissaris, Verhey &
Jolles 1996). In both these studies the interventions proved to be
beneficial for the participants in areas such as compliance and well
being, however, both studies had only a small number of participants
and more research needs to be conducted to support and increase the
potential generalisability their findings. These results and the
results from studies with BD and psychotic participants clearly
demonstrate that psychosocial educational interventions can be
beneficial for people with mental disorders, and this supports the
further use and expanding the implementation of this type of
intervention.
Mechanisms
Various researchers have considered the mechanisms behind the success
of psychosocial educational interventions. Hayes & Gantt (1992)
found that the interventions appear to enhance participants’ sense of
dignity and self esteem due to the increased tools for self-care and
levels of trust placed in his or her hands. Landsverk & Kane (1998)
suggested that the reason as to why psychosocial interventions that
employ psychoeducation are effective is because they increase an
individual’s resilience to stresses, coping skills, manageability,
ability to comprehend life, and the level of their individual life
meaning. In addition, Hayes & Gantt reasoned that the benefits that
result from a psychoeducational intervention maybe derived through
mastery experiences and from increased levels of empowerment.
It seems widely accepted that one of the mechanisms by which
psychosocial educational interventions are effective is in the creation
of a positive cycle involving treatment and rehabilitation. Adhering to
a prescription drug regime allows an individual to take part in
psychosocial interventions, which may in turn increase the knowledge of
his or her mental illness and its treatment, thereby further
facilitating the drug regime adherence. Colom et al. (2005) argued that
the psychoeductaion is based on a tripod model composed of lifestyle
regularity and healthy habits, early detection of prodromal signs, and
treatment compliance. The rest of this review will consider what
specific practical aspects of psychosocial educational interventions
are involved in providing the recorded beneficial effects.
The practical delivery of psychosocial educational interventions
One aspect of psychosocial educational interventions that appears to be
very important is participant’s interactions with their peers.
Ascher-Svanum & Whitesel (1999) stated that individuals can gain
information about their illness by interacting with and listening to
their peers. They argued that the benefits of educating individuals
with mental illness may be due non-specific treatment effects rather
than any specific applied leaning theories. The beneficial non-specific
treatment effects they identified included participant expectations,
motivation to participate, the level of interpersonal support from
study peers, participant opportunities to express and validate their
concerns and questions, the presence of positive peer role models,
being part of a cohesive group, and being able to realise that they
were not alone in their experience of mental illness. In Rummel et
al.’s study (2005) they trained individuals with schizophrenia or
schizoaffective disorder to deliver psychoeductaion to their peers.
They found the outcomes comparable to professionally lead
psychoeductaion. Rummel et al. attributed the effectiveness of their
delivery of psychoeducation to the same advantages of that of peer to
peer interactions mentioned above; they particularly emphasised the
peer instructor’s creditability with their peers and their function as
a role model.
The attributes of the leader, whether they are a professional or a
group peer, of a psychosocial educational intervention are of great
importance to the intervention’s effectiveness. Hayes & Gantt
(1992) stated that a leader needs to hold the belief that those with
mental illness can learn, absorb information, and that they have the
potential to live more productive lives; this is so that they can
communicate hope and the belief in the potential to grow and change.
They also stated that the leader needs to be able to tolerate constant
repetition and a slow pace of learning. In addition, the leader also
needs to be aware of the motivation level, the pace of learning, and
the mood of the group and its members. In their study Hayes & Gantt
(p. 59) found that “the group needed to experience that the leader not
only had the “map” to understand their illness, but the ability to help
guide them through vulnerable states.”
Two other important aspects of a psychosocial educational intervention
are its form and content. Kopolewicz & Liberman (2003, p. 1495)
stated that effective psychosocial educational interventions need to
contain “elements of practicality, concrete problem solving for
everyday challenges, incremental shaping of social and independent
living skills, and specific and attainable goals.” Furthermore, they
stated that “a continuing positive and collaborative relationship
infused with hope, optimism, and mutual respect is central for treating
clients with major mental disorders.” Hayes & Gantt emphasised the
use of group discussions and stressed the value of videotaped content
and reading out handouts in eliciting participant thoughts and in
promoting topics for discussion. In addition, Hayes & Gantt
stressed the importance of involving participants in planning and
choosing the content of interventions so that they meet participant
needs and increase participant commitment to the programme. Kopolewicz
& Liberman noted that motivating an individual to pursue and
complete a psychosocial educational intervention can only be achieved
by connecting the intervention with an individual’s personal goals.
There are specific aspects of an educational programme that will have
differing importance depending on the specific mental disorders of the
participants. For those suffering from depression, Dowrick et al.
emphasised the value of interventions facilitating the acquisition of
problem solving skills. In addition, Klausner et al. (1998) emphasized
the value to depressed individuals of being able to reframe negative
memories and utilize wisdom, flexibility, and resourcefulness to face
challenges and attain goals. For those suffering from schizophrenia and
schizoaffective disorder Hogarty et al. (2004) emphasised the
importance of a cognitive enhancement element to rehabilitation. Many
of those with mental disorders, including those with schizophrenia, can
have problems with attention, concentration, and memory. Emer et al.
(2002) considered the education of individuals who are experiencing
these problems. In their review of the literature they found that
individuals with memory, attention, and concentration difficulties
benefited significantly from instructional methods that included
constant repetition of content to reinforce learning. In addition,
Bisbee (1979, cited in Emer et al. 2002, p. 226) highlighted the need
to use practice, constant feedback, diverse presentation of material,
and discussion groups to enhance the learning of participants with
these types of problems.
For all of those participants with mental disorders taking part in
psychosocial educational interventions the teaching style of those who
deliver the intervention is an important aspect of its effectiveness.
Emer et al. investigated which group teaching style best promotes
information gain for adults with mental disorders and they found that
group formats that enabled member interaction promoted more learning
and retention than lecture formats. In addition, Dowrick et al.
stressed the importance of bearing in mind the fact that potential
participants maybe discouraged from attending a programme that is
didactic in nature due to previous negative experiences of education.
Emer et al. (2002) considered the structure of interactive educational
group formats. They found that higher functioning participants learned
significantly more when the information was presented in an
unstructured format. They argued this could be due to structured
formats interfering with the higher functioning participants’ own
learning approaches, and that they became bored with a structured style
thus reducing their attention, motivation, and learning. Examining the
level of learning results of lower functioning participants, Emer et
al. found that they showed no preference for either a structured or
unstructured format. They stated that this group of participants needed
additional help specifically tailored to their processing needs and
deficits to gain benefits beyond that of a group approach to education.
In addition, Greenberg, Fine, Cohen & Larsen (1988, cited in Emer
et al. 2002) argued that lower functioning participants may find that
the group format is over stimulating or lacks sufficient organisation
for them to benefit from it. These findings suggest that to maximise
learning for both high and low functioning participants they may need
to be educated separately. Emer et al. noted that if this is not
possible, due to time, staff, or financial constraints, then
unstructured formats should be used because they meet the needs of a
greater proportion of participants. A criticism of the Emer et al.
study is that it did not examine whether information gained by the
participants translated into actual life choices, i.e., whether the
participants were applying what they learned. Although change in
behaviour can to some extent result from knowledge gain this is not
always the case. Emer et al. suggests that to facilitate behavioural
changes, motivational and cognitive behavioural methods should be
employed alongside educational interventions.
Summary and future directions
The America Psychological Association (APA) (1997, cited in Kopolewicz
& Liberman 2003, p. 1495) stated that “long-term recovery (from
mental illness) requires comprehensive, coordinated, consistent,
competent, compassionate, and consumer-oriented treatments for
improving the delivery and outcomes of pharmacotherapy and psychosocial
treatments.” Landsverk & Kane’s (1998, p. 420) review found that
there is an “increasing body of evidence of research showing education
to be an effective component in a comprehensive treatment approach to
serious mental illness.” This current review revealed that psychosocial
educational interventions can be beneficial on a wide variety of
measures for suffers of a many different mental health disorders. It
also found that it can empower participants and that this allows them
to collaborate more with their healthcare providers in their treatment
and rehabilitation. In addition, this review revealed the importance in
the provision of psychosocial educational interventions of peer to peer
interactions, the skill and attitudes of the group leader, programme
form and content, goal setting, and a positive group ethos.
Furthermore, the review found that programmes for specific mental
disorders require specifically targeted educational content, and that
low functioning participants may need additional individualised help
beyond that of the group educational format.
In 1998 Landsverk & Kane stated that future research needs to be
conducted to determine the structure, setting, and teaching tools to
optimise the effectiveness of psychosocial educational interventions.
Much has been learnt in the intervening time but there is still a need
for further research to improve the effectiveness and practical
delivery of psychosocial educational interventions for all individuals
who suffer from mental health disorders. The most important point of
this review is that it provides support for the implementation and
further expansion of psychoeducational interventions for those with
mental health disorders. James (2005) stated that to raise the
expectations of a vulnerable learner group, and then take away learning
provision and support after only a short period of time could be
damaging to potential learners and to the credibility of the provider.
It is therefore important that psychosocial educational provision has
long term funding to enable it to be embedded, and to make it
sustainable.
Footnote
This research is funded by the European Union’s EMILIA framework 6
project.
