The International Journal of Psychosocial Rehabilitation

The theories, mechanisms, benefits, and practical delivery of psychosocial educational interventions for people with mental health disorders


Christopher A. Griffiths BSc
Researcher


Middlesex University, UK

Department affiliation: School of lifelong learning
Address: 126 Broad Street, Coventry, CV6 5BG, United Kingdom.
Email: C.Griffiths@mdx.co.uk




  Citation:
Griffiths, C.The theories, mechanisms, benefits, and practical delivery of psychosocial educational interventions
 for people with mental health disorders
  International Journal of Psychosocial Rehabilitation. 11 (1), 21-28




Abstract:
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.


References

Ascher-Svanum, H. & Whitesel, J. (1999). A randomized controlled study of two styles of group patient education about schizophrenia. Psychiatric Services, 50, 926-930.

Authier, J. (1977). The psychoeducation model: definition, contemporary roots and contemporary roots and content. Canadian counsellor, 12, 15-20.

Colom, F. & Lam, D. (2005). Psychoeducation: improving outcomes in bipolar disorder.
European Psychiatry, 20, 359-364.

Colom, F., Vieta, E., Reinares, M., Martinez-Aran, A., Torrent, C., Goikolea, J. M. & Gasto, C. (2003). Psychoeducation efficacy in bipolar disorders: beyond compliance enhancement. Journal of Clinical Psychiatry, 64, 1101-5.

Colom, F., Vieta, E., Sánchez-Moreno, J., Martínez-Arán, A., Reinares, M., Goikolea, J. M. & Scott, J. (2005). Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels. Bipolar Disorders, 7, 32-39.

Commissaris, K., Verhay, F. R. J. & Jolles, J. (1996). A controlled study into the effects of psychoeducation fro patients with cognitive. Journal of Neuropsychiatry, 8, 429-435.

Dowrick, C., Dunn, G., Ayuso-Mateos, J. L., et al. (2000). Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. British Medical Journal, 321, 1450–4.

Emer, D., McLarney, A., Goodwin, M. & Keller, P. (2002). Which group teaching styles best promote information gain for adults with mental disorders? Journal for Specialists in Group Work, 27, 205 – 232.

Gray, M. J., Elhai, J. D. & Frueh, B. C. (2004). Enhancing patient satisfaction and increasing treatment compliance: patient education as a fundamental component of PTSD treatment. Psychiatric Quarterly, 75, 321-32.

Hayes, R. & Gantt, A. (1992). Patient psychoeducation: the therapeutic use of knowledge for the mentally ill. Social Work and Health Care, 17, 53-67.

Hogarty, G. E., Flesher, S., Ulrich, R., Carter, M., Greenwald, D., Pogue-Geile, M., Kechavan, M., Cooley, S., DiBarry, A. L. & Garrett, A. (2004). Cognitive enhancement therapy for schizophrenia: effects of a 2-Year randomized trial on cognition and behavior. Achieves of General Psychiatry, 61, 866-876.

James, K. (2005). NIACE briefing sheet: Learning and skills for people with mental health difficulties. National Institute of Adult Continuing Education. Retrieved 10th June 2006 from:
http://www.niace.org.uk/Research/HDE/Documents/MH_BS.pdf

Klausner, E. J., Clarkin J. F., Spielman, L., Pupo, C., Abrams, R. & Alexopoulos, G. S. (1998). Late-life depression and functional disability: the role of goal-focused group psychotherapy. International Journal of Geriatric Psychiatry, 13, 707-716.

Kopelowicz, A. & Liberman, R. P. (2003). Integration of care: integrating treatment with rehabilitation for persons with major mental illnesses. Psychiatric Services, 54, 1491-1498.

Landsverk, S. S. & Kane, C. F. (1998). Antonovsky’s sense of coherence: theoretical basis of psychoeductaion in schizophrenia. Issues in Mental Health Nursing, 19, 419-431.

Morse, W. C. (2004). Psychoeducational Perspective Overview. University of Michigan - a transcript of spoken commentary. Retrieved 10th March 2006 from:
http://www.coe.missouri.edu/~vrcbd/pdf/PSYPERSP.PDF

Michalak, E. E., Yatham, L. N., Wan, D. & Lam, R. W. (2005). Perceived quality of life in patients with bipolar disorder. Does group psychoeducation have an impact? Canadian Journal of Psychiatry, 50, 96-100.

Mowbray, C. T. & Megivern, D. (1999). Higher education and rehabilitation for people with psychiatric disabilities - statistical data included. Journal of Rehabilitation, Oct-Dec.  Retrieved 10th March 2006 from
http://www.findarticles.com/p/articles/mi_m0825/is_4_65/ai_58575809

Rummel, C. B., Hansen, W. P., Helbig, A., Pitschel-Walz, G. & Kissling, W. (2005). Peer-to-peer psychoeducation in schizophrenia: a new approach. The Journal of clinical psychiatry, 66, 1580-1585.

Wood, M. M., Brendtro, L. K., Fecser, F. A. & Nichols, P. (1999). Psychoeducation: an idea whose time has come. The Council for Exceptional Children, Virginia.




Copyright © 2006 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras