Experienced
Long-Term Benefits Of Group Psychoeducation Among Forensic and Challenging Non-Forensic
Patients with Schizophrenia
Kati Aho-Mustonen, M.A.
University of Joensuu, Department of Psychology
, P.O. Box 111, FIN-80101
Joensuu, Finland
Contact: email:
kati.aho-mustonen@joensuu.fi
Raili Miettinen, M.A.
University of Kuopio
Department of Forensic Psychiatry
Niuvanniemi Hospital, 70240
Kuopio, Finland
Hannu Räty, PhD
University of Joensuu
Department of Psychology
P.O. Box 111, FIN-80101
Joensuu, Finland
Tero Timonen, PhD
University of Joensuu
Department of Psychology
P.O. Box 111, FIN-80101
Joensuu, Finland
Citation:
Aho-Mustonen K, Miettinen R, Räty H & Timonen T. (2009). Experienced Long-Term Benefits Of Group Psychoeducation Among
Forensic and Challenging Non-Forensic Patients with Schizophrenia. International
Journal of Psychosocial Rehabilitation. Vol
14(1). 51-63
Abstract
This study examined the long-term benefits experienced in a brief group psychoeducation pilot
program among forensic and challenging non-forensic patients with schizophrenia
in a forensic hospital setting. Data was obtained by semistructured
thematic interviews with six
long-term schizophrenia patients who attended an eight-time
pilot psychoeducation group four years earlier at the Niuvanniemi Hospital in Kuopio, Finland. Using Antonovsky’s Sense of Coherence Theory as
a theoretical framework, deductive content analysis was used to analyze the
data. Participants experienced benefits from
psychoeducation especially in regard to learning new information about the
illness and reflecting it to their own situation. Participants also experienced a sense of
“shared fate” and noticed that they were not alone in their problems. The aim of
providing new strategies for stress management and coping with their illness
was not sufficiently fulfilled.
Key words: group psychoeducation, schizophrenia,
forensic setting, Sense of Coherence Theory
Introduction
The main principle of psychoeducation is that everyone has the right to
receive information about the illness and treatment in order to take more
active role in relation to the illness instead of being a passive recipient of
care (Cross & Kirby, 2001; Deegan, 1996; McGorry and Edwards, 1997; Mueser
et al., 2002). Schizophrenia patients sometimes know very little about their
diagnosis despite long-term illness (Hornung et al., 1996). Patients usually want information about their illness, and information
should also be provided to those patients who have suffered from schizophrenia
a long time (Chien et al., 2001; Wiersma et al. 1998). It has been shown that even quite brief
interventions can lead to functional improvements in patients with persistent psychiatric
disorders (e.g. Goldman & Quinn, 1988). Chaplin and Timehin (2002) have concluded in their four-year follow-up of a patient
education trial concerning tardive dyskinesia that patients can retain a small
but significant amount of information several years after an intervention. Psychoeducation also constitutes a foundation for
more comprehensive and individualized treatment forms for schizophrenia
patients (Bäuml et al., 2006; Mueser et al., 2002). Psychoeducation can be
regarded as a specific form of psychotherapy (Bäuml et al., 2006) but as Klimitz (2006) has pointed out, if
psychoeducation is seen only within a deficit model of illness and regarded as
merely compliance training, people may only learn to accept the illness; from
the standpoint of recovery psychoeducation can, then, not be regarded as
psychotherapy. Sibitz et al. (2007) have recently studied the perspectives of
non-forensic schizophrenia patients concerning psychoeducation groups and found
that participants specifically emphasize the information received, reflections
on the new information about the illness and life, exchanging information with
other patients, and learning that they are not alone in their situation, as
positive experiences in group psychoeducation. It is recommended that structured psychosocial
group interventions also be integrated into the treatment of forensic patients,
i.e. offenders with psychiatric illness; psychoeducation is nowadays considered
an important component in the comprehensive treatment of these patients (Cross
& Kirby, 2001; Duncan et al., 2006). Schizophrenia patients in forensic psychiatry
are often hospitalized for many years and the treatment poses many challenges
as a result of the severity of the patients’ illness, the often persistent
symptomalogy, and many related problems, such as aggressive behaviour. Individualized
treatment programs with individually adapted components are needed to target
the problems of different kind of forensic patients (Hodgins, 2002). Cross and Kirby (2001) have postulated that in
forensic settings many patients feel quite hopeless about the prospect of
change, and the main purpose of psychoeducation is therefore to combat stigma,
and help forensic patients take more
responsibility for their own care and thus live more meaningful lives. The effectiveness of patient
psychoeducation has only rarely been studied among forensic schizophrenia
patients (see Aho-Mustonen et al., 2008; Jennings et al., 2002). Recovery can be conceptualized
as an attitude or life orientation (Resnick et al., 2005), and although forensic
patients are often treated differently than other patients and may have limited
opportunities for recovery (see Porporinio & Motiuk, 1995), a recovery
orientation to psychiatric illnesses has also recently been adopted in the
field of forensic psychiatry (see for example Barsky & West, 2007). Maintaining and instilling hope is an essential
feature in the recovery process of the people with severe psychiatric illnesses
(Byrne et al., 1994; Clayton & Tse, 2003; Coleman, 1999; Czuchta & Johnson, 1998; Kelly & Gamble, 2005; Kirkpatrick et al. 1995;
Kylmä et al., 2006; McCann, 2002; Spaniol, 2008). Interventions
in psychiatric settings can serve as
recovery goals directed towards persons with psychiatric illness, for example,
in terms of social and instrumental support, learning and practicing coping
strategies to manage their illness and achieving individual goals, and
supporting the self-efficacy and self-esteem of the patients (Corrigan, 2003;
Mueser et al., 2002; Mueser et al., 2006). For example Anderson et al. (2001)
have earlier presented a recovery oriented brief psychoeducational group
therapy program for the dually diagnosed patients in inpatient and residential
settings. The present study adopted the
view that recovery from psychiatric illness is a process of taking back control
and living a satisfying life despite of the illness, whereas wellness can be
experienced in spite of symptoms, and at any point of the process of recovery (Anthony, 1993; Deegan, 1996; Hutchinson et al.,
2006; Kelly & Gamble, 2005; Mullen 1986; Spaniol
et al., 2002; Spaniol, 2008; Thornton, 2000). Feeling that one has no control over one’s illness can
cause hopelessness and eventually lead a person to abandon responsibility and
active coping strategies; hence, this has a significant role in the efficacy of
treatment and rehabilitation, and the long-term course and outcome of
schizophrenia (Birchwood et al., 1993; Deegan, 1996; Hoffmann, Kupper &
Kunz, 2000). It is important that interventions aimed at recovering from mental
illness emphasize a hope-promoting environment, processes and strategies such
as acceptance of the illness (Hatfield & Lefley, 1993); access to objective information and education
(Kirkpatrick et al. 1995; McCann, 2002); viewing
persons with psychiatric illness as people, increasing their dignity,
self-esteem, self-efficacy, and self-worth, and promoting meaning, mastery
and motivation (Coleman, 1999; Kirkpatrick et al., 1995; McCann, 2002; Snyder
et al., 2000). It is also important to validate patients’ coping strategies,
experiences, and help them with problem-solving, illness management and
self-management (Kirkpatrick et al., 1995; Snyder et al., 2000). Coffey
(2006) has pointed out that we still do not know much of the experiences of
people who use forensic mental health services. The present study was the pilot
phase of larger study of the effectiveness of group psychoeducation among
forensic patients and the results have been utilized in designing a larger
controlled study about the efficacy of group psychoeducation among these
patients. The present study sought to examine experiences concerning benefits
of group psychoeducation four years after the intervention from a participant
perspective. The study questions were: 1) what kind of recollections do the
participants have concerning the psyhoeducation group they had attended four
years earlier and 2) what are the experienced long-term benefits of group
psychoeducation program that participants express and attach to their group
experience. Theoretical framework
Landsverk
and Kane (1998) have postulated that the processes that result in an effective
outcome in psychoeducation are still unknown and therefore proposed the Sense
of Coherence Theory developed by Antonovsky (1979, 1987) as a potentially useful
framework for conceptualizing the effectiveness of comprehensive
psychoeducational programs. They have
also
recommended that psychoeducation programs should be aimed at schizophrenia
patients with persistent illness in institutional settings, since in this
context intentionally modified changes in SOC may be possible. According
to Antonovsky (1987), individuals move back and forth on a health-disease
continuum through life; he calls this orientation the salutogenic model of
health. Of major importance in determining a person’s relative position on this
continuum is his/her Sense of Coherence (SOC). The sense of
coherence construct relates to how individuals assess and cope with stressful
situations; the sound management of stressors, explained by Antonovsky, is
salutogenesis. The three elements
of the SOC are: (1) Comprehensibility – which refers to the cognitive
controllability of one’s environment, that the world is interpreted as
rational, understandable, structured, ordered, consistent and predictable; (2)
Manageability - the extent to which individuals believe they have personal
access to adequate resources for coping with challenges, demands or problems in
the environment; (3) Meaningfulness - the subjective feeling that life makes
sense and that at least some parts of our life are worthy of commitment and
engagement. Meaningfulness can also be considered as an emotional component of
the SOC (Antonovsky, 1987). Landsverk and Kane (1998) have proposed that an effective
psychoeducational model encompasses the three main components contributing to
SOC, and in this way psychoeducation works to maintain and enhance an
individual’s sense of coherence. Bengtsson-Tops and Hansson (2001) have also
suggested that the salutogenic perspective might contribute to well-being among
patients with schizophrenia in many advantageous ways. Therefore Antonovsky’s theory was applied as a theoretical tool in the present study for studying the
experienced benefits of group psychoeducation for schizophrenia patients. The compatibility of the SOC theory with psychoeducation and the
treatment of schizophrenia concerns the relationships between stress, health and coping.
Schizophrenic disorders are nowadays understood on the basis of the
vulnerability/stress model of mental disorders, first time proposed by Zubin
& Spring (1977). In treating schizophrenia a fundamental aim is to reduce vulnerability to life stress and chronic
symptom recurrence, as, for example, Nuechterlein & Dawson (1984), have postulated. Since patients in
this study suffered from a difficult, long-term illness with persistent
symptoms, the salutogenic orientation also seemed relevant in this context. Thus,
the goals of the intervention were not to find a cure for the illness, but to
improve the patients’ situation and move closer towards positive end of the
health-disease continuum. The benefits of psychoeducation have also been
postulated to be largely due to non-specific treatment factors (e.g. social
support and facilitation and promotion of a shared fate and hope) than due to
specific active therapeutic ingredients (Ascher-Svanum & Whitesel, 1999; Bäuml
et al., 2006; Sibitz et al., 2007). The SOC theory with its three components is
therefore conceptually feasible as it captures both the possible specific and
non-specific experienced effective aspects of group psychoeducation. Method
Participants in the present study were 4 male forensic patients, i.e. mentally
disordered offenders who had found to lack criminal responsibility for crimes
committed and instead admitted to an involuntary psychiatric treatment, and 2
difficult to treat or dangerous non-forensic long-term patients, who met the DSM-IV criteria (American Psychiatric Association, 1994) for a
primary diagnosis of schizophrenia, and who had attended
the psychoeducation pilot group four years earlier. Also
the non-forensic patients in the present study were in involuntary treatment. The
pilot intervention was conducted in summer 2001 at the Niuvanniemi Forensic Mental Hospital in Kuopio, Finland. 5 of the 7 patients who initially participated in the intervention were
still hospitalized at Niuvanniemi Hospital, and 2 were treated in psychiatric
rehabilitation homes. One participant who was no longer hospitalized was not
allowed to be interviewed due to his psychiatric state at that time. Participants
had severe illness, and at the time of pilot intervention they had been
hospitalized in Niuvanniemi Hospital continuously on average over seven
years. The mean age of the group was 39.2 years (SD=5.8 years), and the mean
GAF, assessed by the doctor in charge of each participants care, was 35.5 (SD=8.5).
Clinical characteristics of the group participants at the time of pilot
intervention in 2001 are presented in Table 1. Table 1.
Clinical characteristics of the group participants at the time of pilot intervention in 2001.
Participant
|
Age
|
Current treatment started
|
Admission status
|
Primary diagnosis
|
Substance abuse
|
Personality disorder
|
|
Aaro
|
45
|
1986
|
Forensic
patient/
Attempted
homicide
|
Other
schizophrenia
|
Alcohol
dependence
|
Yes
|
|
Samuel
|
34
|
1995
|
Forensic
patient/
Aggravated
robbery
|
Undifferentiated
schizophrenia
|
Multiple
drugs dependence
|
No
|
|
Juha
|
31
|
1995
|
Difficult to treat patient/
Violence
|
Hebephrenic schizophrenia
|
No
|
No
|
|
Leo
|
44
|
1998
|
Difficult to treat patient/
Aggressiveness
|
Hebephrenic schizophrenia
|
Multiple drugs dependence
|
No
|
|
Tatu
|
38
|
1988
|
Forensic patient/
Attempted homicide
|
Undifferentiated schizophtneia
|
Alcohol dependence
|
Yes
|
|
Ilkka
|
43
|
2000
|
Forensic
patient/
Attempted
homicide
|
Undifferentiated
schizophrenia
|
Alcohol
dependence
|
Yes
|
The eight-time psychoeducational program used in pilot study was adapted
and modified from Ascher-Svanum and Krause’s (1991) “Psychoeducational Groups
for patients with Schizophrenia”. The group intervention goals sought to
provide information about schizophrenia and coping with the illness.
Maintaining and instilling hope was emphasized, and sharing one’s thoughts and
group discussion were encouraged. Topics covered in the group sessions
included: orientation, definition of schizophrenia and common symptoms,
diagnosis and etiology of schizophrenia, course of illness, outcome of
schizophrenia and warning signs of relapse, causes of schizophrenia,
stress-vulnerability model and the influence of stress, substance abuse in
schizophrenia, antipsychotic medication, treatment of schizophrenia, and legal
issues. In addition program contained cognitive-behavioral elements, and
participants were, for example, assigned homework between group sessions. A
normalizing rationale to explain symptom emergence in schizophrenia was used.
The group met once a week and the sessions were 45-60 minutes long. The
sessions were conducted by two psychologists (the first and second authors of
this article). The
intervention group utilized a leader manual.
The follow-up data
was obtained by semistructured individual thematic interviews which contained
questions about the participants’ recollections and experiences of the
intervention group four years earlier. The participants were first asked to
describe in their own words what they could recall from the group. Then
complementary thematic interviews were conducted, where more specific questions
about their experiences and memories of the group were asked. Interviews were conducted by the first author
during the summer of 2005 and were 45-90 minutes long. All but one was
audiotaped. Because one participant refused permission to audiotape the
interview, his interview was conducted by making extensive notes.
The interviews were transcribed verbatim. In the analyses deductive content analysis,
where the structure of the analysis is based on previous knowledge (see Elo
& Kyngäs, 2008), was applied. The three major categories were derived from
Antonovsky’s Sense of Coherence Theory. The interviews were read and reread by
the first author and the expressed benefits were extracted from the text and
classified under the three main components of SOC. The categories captured the
experiences of the participants very well, as they could be seen to represent a
wide range of possible aspects of the intervention (cognitive, behavioral, emotional).
Although in previous research comprehensibility has sometimes been seen as a
cognitive, manageability as a behavioral, and meaningfulness as a spiritual and
emotional component of SOC (see, e.g., Rabin et al., 2005), there is some
overlap between categories. For example, in the present study “gaining
information” could be categorized to be an experienced benefit in terms of both
comprehensibility (more understanding about the illness) or manageability
(information as a resource to cope better). Gaining information or understaning
were categorized under comprehensibility but if the answer referred more to new
skills and behavioral aspects, for example, “learning to search for new
information” it was categorized under manageability. Citations from the
interviews were used to increase the reliability of the findings (see Coffey,
2006; Elo & Kyngäs, 2008; Graneheim & Lundman, 2004).
Ethical considerations
Ethical approval for the research was obtained
from the Research Ethics Committee of Kuopio University Hospital. All
participants were told that they were free to withdraw at any time and this
would have no bearing on their treatment. Written informed consent was obtained
from all participants for both the interview and research, as well as for
information to be obtained from their treatment records. To guarantee
confidentiality and anonymity, the interviews were coded and no citations that
could reveal the identity of the informant were used. The names of the
participants were changed. Due to the vulnerability of the group participants
and the very sensitive, difficult issues discussed in the interviews, the
participants were guaranteed that no person other than the main researcher
would have access to the original interviews.
Results
To guarantee confidentiality and anonymity of
the participants their names were changed. In text participants are called
Aaro, Samuel, Juha, Leo, Tatu and Ilkka.
All the participants could remember
the interviewer, who had acted as a group leader in the psychoeducation group.
Aaro, Juha and Ilkka had the most specific memories about the group. Samuel and
Tatu could summon up memories about the group in mainly general terms and could
share their experiences of the group only after focusing the themes and
questions in more specific terms. Leo was the only one who could not recall the
intervention at all. Participants
who remembered the group considered it to have been helpful in their situation.
The benefits of group psychoeducation for each patient were assessed by
using the following overall categories derived from Antonovsky’s SOC theory with
its three main components as categories (Table 2). “Comprehensibility” referred
to cognitive aspects of experienced benefits and included themes such as
gaining new information about schizophrenia and its treatment and restructuring
one’s experiences as experienced benefits of the group. “Manageability” included themes involving
different resources and skills gained and experienced as helpful in the group,
and the emphasis was on behavioral aspects considered to be beneficial. Gaining new skills concerning coping with
stress, managing with persistent symptoms, monitoring of early warning signs,
seeking help and information, and peer support were included in this category. “Meaningfulness” included
motivational and emotional aspects and themes, for example, answers involving hope,
identification with appropriate role models, sharing, empowerment, reasonably
challenging activities and optimism. When
a participant expressed benefits from more than one category, the primary and
secondary benefits experienced were determined by making the category with more
accounts the primary category.
Table 2. Experienced benefits of group psychoeducation
in the study group.
|
|
Comprehensibility
|
Manageability
|
Meaningfulness
|
|
Aaro
|
++
|
-
|
+
|
|
Samuel
|
++
|
-
|
+
|
|
Juha
|
++
|
-
|
+
|
|
Leo
|
-
|
-
|
-
|
|
Tatu
|
+
|
-
|
-
|
|
Ilkka
|
++
|
+
|
+
|
Note. ++ = primary experienced benefit, + = secondary experienced benefit, - = no experienced benefit
Comprehensibility
The results show that the benefits gained from
the psychoeducation group came mainly in terms of new information and improved
comprehensibility, although participants emphasized that they had forgotten a
lot about the group during the four intervening years. The group seemed to work
as a new, confidential forum where it became possible for the participants to obtain
new information about the illness, ask questions, and get them answered. Aaro, Samuel and Juha mentioned that getting
new information was the very best thing in the whole group experience.
Respondents also emphasized their belief that this new information appeared to
be reliable. The need for information was evident: Aaro, Juha and Tatu felt
that before the group they had “some knowledge of schizophrenia”, but not
enough. Samuel reported that before the group his level of knowledge was
“zero”.
Human beings have an innate need to
understand and have control over their lives. As Aaro stated in the interview “there should be an explanation, a
reason for everything”. Psychotic
illness and symptoms can often be very confusing and even frightening and people have a need to know what
is happening to them. Aaro gave an
example of fears that troubled him:
I have had fears that I would become disabled,
break a limb or something, or maybe something unexpected happens … I would have
to be in a hospital for the rest of my life or suffer some injuries, immobility
… Or maybe I would lose my mind for good. These are the things I wonder about.
It was hoped
that the information offered would give the patients a chance to reinterpret
and reorganize their experiences. It was evident in the interviews that
participants were able to reflect on this new information in their personal
situations and structure their experiences:
The information that was given about
the symptoms, I think it was all true … I found out things about my own life …
and thought about those things again and remembered things I had not remembered
before … I was able to dredge up
memories from my past. I think that without this group I would have never been
able to talk about those things, here or elsewhere either. (Aaro)
Yes, yes. I found out that there can
be almost same diseases, it was something really good to hear … you get a
social phenomenon there that helps in healing…I was able to realize that
earlier I didn’t understand my own thoughts, that was the feeling I got, what
it really is to be in psychosis. … I think I realized that even before, but now
I am sure ... I need help. (Juha)
Manageability
One of the main aims
of the intervention was to
provide the participants with new strategies for coping with their illness and
ways of handling stress better. In research interviews the participants were asked about
the new coping skills and strategies they had learned. Only Ilkka could refer
more specifically to the coping strategies he had learned in the group:
For example, how do you know that
you could get so seriously ill,
and what the first symptoms and signs are … how you can prevent the worsening
of symptoms and when you should go to the doctor or notice that things are getting worse.
The participants
were also assigned homework between group sessions to help them practice new
skills for coping. In the interviews, all the participants said that they had
done at least part of the assignments but, on the other hand, none of them
could recall the exact contents of these assignments:
I guess I
scrawled something on the papers, as far as I can recall. (Aaro)
Meaningfulness
One aim of the
intervention was encourage sharing in the group, and in the light of the interviews this supportive
environment was clearly realized.
Group rules were created to support the structure of the group and help build
an atmosphere of confidence and sharing for the participants. For example,
Samuel emphasized that “keeping one’s mouth shut” was the most important rule
in the group and admitted that without such a rule he would not have even
participated in it. Other patients stressed the importance of confidentiality
in the interviews as well:
It was quite
good that you get a chance to (speak)...confidentially, you don’t have to be
afraid that you hear those things while walking down the corridors. (Aaro)
The participants
believed that confidentiality worked well. For example, Aaro was able to share the very
sensitive and personal difficult experiences of his illness. Samuel also shared
his experiences about psychosis, alcohol abuse, and side-effects of his
medication with the group, even though his medical records from that time
postulated that he could not discuss his mental problems at all. The atmosphere
of mutual understanding and confidentiality were probably of great importance
in permitting him to dare to share his feelings and experiences.
Patients with schizophrenia often believe that
their condition is very rare and uncommon. A normalizing rationale for explaining the emergence of symptoms in
schizophrenia was therefore used in the group. Medical analogies were used to normalize mental illness and show
schizophrenia to be a treatable illness. Patients found hope in the notion that
they are not alone in their situation:
I found out that my illness is not that bad after
all ... I can speak about it with other patients in my ward ... we won’t be
here forever ... some day I’ll get out of the hospital...They had the same problems, almost,
almost the same kinds … I felt that I am not alone after all, that others have
the same things. (Aaro)
Sharing one’s experiences can be
empowering and foster hope, but it can also be emotionally difficult for the
patients:
I have had discussions about my
mental illness so many times with doctors and psychologists ... they have asked
whether I hear voices ... everything about ... how I felt and how I was doing
when I stabbed that guy ... Sometimes it feels very bad ... now I can tell you
that when the stabbing happened, I actually heard voices, I really was a sick
man. Sometimes I just feel that I don’t want to talk about it all the time ...
those are such bad memories, really bad. (Ilkka)
Despite this statement, Ilkka noted in the
interview at the end of the group that he had a positive feeling about it. Also
Aaro and Samuel said that sharing experiences was sometimes difficult and made
them feel bad; on the other hand, an opportunity to share and listen to the
experiences of others was viewed as interesting, and the information about the
universality of schizophrenia and the experiences of others were considered to
be a relief. A shared experience of illness or “shared fate” was evident also
in following quotation:
We are all fellow sufferers here.
All people have their own things, but we all have got to the hospital ... I
think what we have in common is that everyone of us walks the same road,
schizophrenia is the reason why we have to stay here. (Tatu)
If patients are
offered a sufficient
level of challenge, it could imply their sense of meaningfulness (Bengtsson-Tops
& Hansson, 2001). Therefore these challenges of learning new things were
offered in the group, but always kept in mind the participants’ personal
abilities and limitations. For
people, who appreciate and can easily adopt the school-like structure, the
group format with its lessons and written material can be very important. Juha,
who had graduated from upper secondary school before he became ill, stated:
The written material was the number one thing,
for me at least.
The meaningfulness of the group experience can
also be understood as an active attempt to take part in one’s own treatment:
For example, Leo, who did not even
recall attending the psychoeducational group, brought out in the interview that
he has serious memory problems; despite this, he said he wants to take part in all kinds of
therapeutic activities in the ward because he wants to “rehabilitate the
brain”. He explained:
But my brain just doesn’t work … it
is ramshackle … it doesn’t work at all … this situation comes near to brain
damage … and probably is brain damage
... I take part in different interventions just because of interest, and of
course I hope that maybe they could help me in some way … interest is the main
reason (to participate).
Although Leo could not recall the group, he emphasized that groups are
in general important and meaningful to him in terms of active participation in
his own treatment and help him maintain hope in his difficult situation.
Discussion
The present study sought to examine the experienced benefits of group
psychoeducation four years after the intervention from a participant
perspective. The findings suggested that participants had fairly positive
experiences, especially in regard to comprehensibility, and were able to take
in information about the illness and adapt it to their own situation. The study
supported the findings of previous research that psychoeducation has beneficial
effects and also long-term psychiatric
patients need and want information about their illness, consider that information to be
helpful in their situation and give them hope even if they have suffered from schizophrenia for several years (Bäuml et al., 2006; Chien et al., 2001; Griffiths, 2006; Wiersma et al.
1998). Participants were able to reflect on this new
information in their personal situations and structure their experiences in such a way that the information became the
participant's personal knowledge, in the same way as Kilkku et al. (2003) found in their study. Participants,
however, emphasized that they had forgotten a lot about the group during the
four intervening years, which is consistent with some previous findings that
patients can internalize information, but booster sessions are probably needed
to consolidate learning (Macpherson, Jerrom, & Hughes, 1996; Zygmunt et
al., 2002).
Most participants
in this study also experienced benefits related to meaningfulness and perceived the group as beneficial since it gave
them a new sense of hope for the future. The benefits from psychoeducation included a
sense of “shared fate” and a chance to note that they are not alone in their
problems; all of these issues are related to the individual’s sense of
coherence. The opportunity to
share and listen to the experiences of others was viewed as interesting, and
the information about the universality of schizophrenia, i.e. the notion that
they are not alone in their situation, and shared discussions were experienced
as important and mitigating. These findings concur with what Kilkku et al.
(2003) found studying the meaning of information-giving to patients with first-episode
psychosis. Sharing difficult
experiences can reduce the feeling of isolation and enhance the sense of
belonging, but it can also be emotionally difficult for patients. This issue
was illustrated in present study as the group was seen as difficult but
helpful.
As Spaniol et al. (2002, 2008) have noted, gaining control over the
illness requires having effective coping skills and strategies for dealing with
symptoms and stressors. Although one of the main aims of the intervention
was also to provide the
patients with new strategies for stress management, coping with their illness
and ways of handling stress better, this aim was not sufficiently fulfilled. Still, all the participants who remembered
attending the group expressed satisfaction with the group experience and
considered group psychoeducation to have been helpful in their situation. It has been proved that forensic schizophrenia
patients can also develop skills and roles when provided with meaningful
rehabilitation (Schindler, 2005). Compared to those studies where the effectiveness
in terms of skills has been proved, the group program presented here was of
short duration. Clearly longer and more intensive interventions are needed to
help these patients adopt new active coping strategies for managing their
symptoms and illness.
It has been recommended that we also
give patients whose illness affects their cognitive functioning an opportunity
to participate in psychosocial interventions (Bengtsson-Tops & Hansson,
2001; Välimäki et al., 1996). In this study, participants’ cognitive deficits
and disturbances were taken into account when planning the intervention, and
visual aids and other techniques were used. Leo, who suffered from substantial
cognitive problems and thought disorder, could still not even recall he had
attended the group four years earlier. Massive formal thought disorder has
been, in fact, been defined in recent research as one of the few mandatory
contraindications to psychoeducation (Bäuml et al., 2006), but the aim of the present study was to also give
those patients, who prior to this group very seldom had a chance to participate
in any psychosocial group interventions, an opportunity, as it has been
postulated that interventions with unconditional support and zero exclusion as
principles can provide hope to patients with persistent illness and support
individuals’ recoveries (Bäuml et al., 2006; Mueser et al. 2002).
Findings in the present
study are largely similar to those of Bäuml and his colleagues (2006), who have found that the specific
effective factors of psychoeducation seem to be the illness-related key information
and emotional topics, and those obtained from Sibitz et al. (2007), who found
that participants especially emphasized the information received, reflecting
the new information about illness and life, exchanging information with other
patients, and learning that they are not alone in their situation, as positive
experiences in group psychoeducation.
Participants expressed very few benefits connected to manageability or the
behavioral level of the outcomes. These results are also in line with previous
research. It has previously been recognized that even though behavioral changes
are not achieved, psychoeducation can still enhance the participants’ quality
of life by offering information and a chance to share experiences, and that it
creates a useful foundation in the treatment of schizophrenia. Other and more
comprehensive long-term treatment efforts and methods need to be applied in addition
to brief pychoeducational groups, especially in the treatment of patients with
persistent illness (see, e.g., Bäuml et al., 2006; Kilian et al., 2001; Mueser
et al., 2002) but
psychoeducational programs can serve as a basic therapeutic component even
though more individualized treatment are needed to target the specific problems
of forensic patients (Hodgins, 2002)
Because of the nature of the participants’ illness and the criminal
offenses they had committed, durations of inpatient treatment are often very
long and most of the participants in the present study were still hospitalized
four years after the intervention. It is therefore impossible to estimate
whether the intervention shortened the duration of treatment among these
participants. Participants still found the intervention helpful and expressed
benefits from it even four years after attending the group.
There are limitations concerning the present
study. As indicated above, due to ethical reasons the inter-rater reliability
of the analysis was not possible to assess, and the issues of credibility and transferability were taken
into account by using quotations from the original interview material in the
text. The sample in this study, due to the study’s pilot nature, was also very
small, which may reduce the transferability of the present findings to other
contexts.
Conclusions
Comprehensibility, manageability and
meaningfulness proved to be useful concepts for understanding the experienced
benefits, related both to the active treatment factors and more non-specific
effective treatment factors that psychoeducation produces for the participants. The findings of the present study support the idea that long-term
psychiatric inpatients gained new information about their illness from the psychoeducation
group and considered
the information obtained to be helpful in their situation and gave them hope, even though they had suffered from
schizophrenia for several years. Our results indicated that for some participants
the group acted as a forum where a new understanding of their situation was
gained. It would be advantageous that as many patients as possible be given a
chance to participate in psychoeducation groups, because psychoeducation groups with a recovery
orientation may provide their participants a new sense of hope and empowerment, and for some people even a unique context to
discuss the very sensitive issues that would be difficult to discuss in other circumstances.
Further research with a larger
sample will be conducted based on results obtained from the present study.
References
Aho-Mustonen,
K., Miettinen, R., Koivisto, H., Timonen, T. & Räty, H. (2008). Group psychoeducation for forensic and
dangerous non-forensic long-term patients with schizophrenia. A pilot study. The European Journal of Psychiatry, 22(2),
84-92.
American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders (4th edition). Washington, DC:
APA; 1994.
Anderson,
A.J., Boris, S. & Kleckham, J. (2001). Psychoeducational group
therapy for the dually diagnosed. International Journal of Psychosocial
Rehabilitation, 5, 77-78
Anthony, W.A. (1993). Recovery from mental
illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation, 16(4), 11-23.
Antonovsky, A. (1979). Health, Stress and Coping. London: Jossey-Bass Publishers.
Antonovsky, A. (1987). Unraveling the Mystery of Health: How People Manage Stress and Stay Well.
San Francisco: Jossey-Bass Publishers.
Ascher-Svanum, H. and Krause, A. (1991). Psychoeducational
Groups for Patients with Schizophrenia. Gaithersburg, MD:
Aspen Publishers.
Ascher-Svanum, H. & Whitesel, J. (1999). A
randomized controlled study of two styles of group patient education about
schizophrenia. Psychiatric Services, 50,
926-930.
Barsky, J. & West, A.G. (2007). Secure
settings and the scope for recovery: service users’ perspectives on a new tier
of care. The British Journal of Forensic Practice,
9(4), 5-11.
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(S1), S1-S9.
Bengtsson-Tops, A. & Hansson, L.
(2001). The validity of Antonovsky’s sense of coherence measure in a sample of
schizophrenic patients living in the community. Journal of Advanced Nursing, 33(4), 432-438.
Birchwood, M., Mason, R., MacMillan,
F. & Healy, J. (1993). Depression, demoralization and control over
psychotic illness: a comparison of depressed and non-depressed patients with a
chronic psychosis. Psychological
Medicine, 23(2), 387-395.
Byrne, C.M., Woodside, H., Landeen,
J., Kirkpatrick, H., Bernardo, A. & Pawlick, J. (1994). The importance of
relationships in fostering hope. Journal
of Psychosocial Nursing and Mental Health Services, 32(9), 31-34.
Chaplin, R. & Timehin, C.
(2002). Informing patients about tardive dyskinesia: four-year follow up of a
trial of patient education. Australian
and New Zealand Journal of Psychiatry, 36, 99-103.
Chien, W.-T., Kam, C.-W. & Lee, I.F.-K.
(2001). An assessment
of patients’ needs in mental health education. Journal of Advanced Nursing, 34(3), 304-311.
Clayton, J. & Tse, S. (2003). An
educational journey towards recovery for individuals with persistent mental
illnesses: A New Zealand perspective. Psychiatric
Rehabilitation Journal, 27(1), 72-78.
Coffey, M. (2006). Researching
service user views in forensic mental health: A literature review. The Journal of Forensic Psychiatry &
Psychology, 17(1), 73-107.
Coleman, R. (1999). Recovery: An Alien Concept. Gloucester: Handsell Publishing.
Corrigan, P.W. (2003). Towards an
integrated, structural model of psychiatric rehabilitation. Psychiatric Rehabilitation Journal, 26(4), 346-358.
Cross, D. & Kirby, S.D. (2001). Using psychoeducational
interventions within an integrated psychological approach to forensic mental
health and social care. In A.M. Kettles, (Ed.), Therapeutic Interventions for Forensic Mental Health Nurses (pp. 72-91). London: Jessica Kingsley Publishers.
Czuchta, D.M. & Johnson, B.A.
(1998). Reconstructing a sense of self in patients with chronic mental illness.
Perspectives in Psychiatric care, 34(3),
31-36.
Deegan, P. (1996). Recovery as a
journey of the heart. Psychiatric
Rehabilitation Journal, 19(3), 91-97.
Duncan, E.A.S., Nicol, M.M., Ager, A.
& Dalgleish, L. (2006). A systematic review of structured group interventions
with mentally disordered offenders. Criminal
Behaviour and Mental Health, 16,
217-241.
Elo, S. & Kyngäs,
H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115.
Global Assessment of Functioning Scale (GAF),
in Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV): Washington, DC,
American Psychiatric Association, 1994.
Goldman, C.R. & Quinn, F.L. (1988). Effects
of a patient education program in the treatment of schizophrenia. Hospital and Community Psychiatry, 39,
282-286.
Graneheim, U.H. & Lundman, B. (2004).
Qualitative content analysis in nursing research: concepts, procedures and
measures to achieve trustworthiness. Nurse
Education Today, 24, 105-112.
Griffiths, C. (2006). 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.
Hatfield, A.B. & Lefley, H.P. (1993). Surviving mental illness: Stress, coping and
adaptation. New York: Guilford Press.
Hodgins, S. (2002). Research proprieties in forensic mental health.
International Journal of Forensic Mental Health, 1, 7-23.
Hoffmann, H., Kupper, Z. & Kunz, B. (2000). Hopelessness and its impact on rehabilitation
outcome in schizophrenia – an exploratory study. Schizophrenia Research, 43, 147-158.
Hornung, W.P., Kieserg, A., Feldmann, R. &
Buchkremer, G. (1996). Psychoeducational
training for schizophrenic patients: background, procedure and empirical
findings. Patient Education and
Counseling, 29, 257-268.
Hutchinson, D.S., Gagne, C., Bowers, A., Russinova, Z.,
Skrinar, G.S. & Anthony, W.A. (2006). A framework for health promotion
services for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29(4), 241-250.
Jennings, L., Harris, B., Gregoire, J., Merrin, J.,
Peyton, J. & Bray, L. (2002). The effect of a psycho-educational programme
on knowledge of illness, insight and attitudes towards medication. The British Journal of Forensic Practice, 4,
3-10.
Kelly, M. & Gamble, C. (2005). Exploring
the concept of recovery in schizophrenia. Journal
of Psychiatric and Mental Health Nursing, 12, 245-251.
Kilian, R., Lindenbach, I. & Angermeyer, M.C.
(2001). “(...) sometimes I have
doubts about myself, when I’m not doing well.“ Effect of an ambulatory
psychoeducational group program from the subjective perspective of patients
with schizophrenic illnesses. Psychiatric
Praxis, 28, 168-173.
Kilkku, N., Munnukka, T. & Lehtinen, K.
(2003). From information to knowledge: the meaning of information-giving to
patients who had experienced firs-episode psychosis. Journal of Psychiatric and Mental Health Nursing, 10, 57-64.
Kirkpatrick, H., Landeen, J., Byrne, C.,
Woodside, H., Pawlick, J. & Bernardo, A. (1995). Hope and schizophrenia:
clinicians identify hope-instilling strategies. Journal of
Psychosocial Nursing and Mental Health Services,33(6), 15-19.
Klimitz, H. (2006). Psychoedukation bei schizophrenen Störungen –
Psychotherapie oder “Unterwanderung”? Psychoeducation in schizophrenic disorders – Psychotherapy or
“infiltration”? Psychiatric Praxis, 33, 372-382.
Kylmä, J., Juvakka, T., Nikkonen, M., Korhonen,
T. & Isohanni, M. (2006). Hope and schizophrenia: an integrative review. Journal of Psychiatric and Mental Health
Nursing, 13, 651-664.
Landsverk, S.S. & Kane, C.F. (1998). Antonovsky’s sense of coherence:
theoretical basis of psychoeducation in schizophrenia. Issues in Mental Health Nursing, 19, 419-431.
MacPherson, R., Jerrom, B. & Hughes, A.
(1996). A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry, 168,
709-717.
McCann, T.V. (2002). Uncovering hope
with clients who have psychotic illness. Journal
of Holistic Nursing, 20(1), 81-99.
McGorry, P. & Edwards, J. (1997). Early Psychosis
Training Pack. Victoria Mill, Australia:
Gardiner-Caldwell Communications.
Menzies, V. (2000). Depression in schizophrenia: nursing care as a
generalized resistance resource. Issues
in Mental Health Nursing, 21, 605-617.
Mueser, K.T., Corrigan, P.T., Hilton, D.W.,
Tanzman, B., Schaub, A., Gingerich, S., Essock, S.M., Tarrier, N., Morey, B.,
Vogel-Sciblia, S. & Herz, M.I. (2002). Illness management and recovery: a
review of the research. Psychiatric Services, 53, 1272-1284.
Mueser,
K.T., Meyer, P.S., Penn, D.L., Clancy, R., Clancy, D.M. & Salyers, M.P.
(2006). The illness management and
recovery program: Rational, development, and preliminary findings. Schizophrenia Bulletin, 32 (Suppl. 1), S32-S43.
Mullen, K.D. (1986).
Wellness: the missing concept in health promotion programming for adults. Health Values, 10(3), 34-37.
Nuechterlein, K.H. & Dawson, M.E. (1984). A heuristic
vulnerability/stress model of schizophrenic episodes. Schizophrenia Bulletin, 10(2),
300-312.
Porporino
F.J. & Motiuk, L. L. (1995). The prison careers of mentally disordered
offenders. International Journal of Law
and Psychiatry, 18(1), 29-44.
Rabin, S., Matalon, A., Maoz, B. & Shiber,
A. (2005). Keeping doctors healthy: A salutogenic perspective. Families, Systems, & Health, 23(1),
94-102.
Resnick, S.G., Fontana, A., Lehman, A.F. & Rosenheck, R.A.
(2005). An empirical conceptualization of the recovery orientation. Schizophrenia Research, 75, 119-128.
Schindler, V.P. (2005). Role development: an
evidence-based intervention for individuals diagnosed with schizophrenia in a
forensic facility. Psychiatric
Rehabilitation Journal, 28(4), 391-394.
Sibitz, I., Amering, M., Gössler, R., Unger, A.
& Katsching, H. (2007). Patients’
perspectives on what works in psychoeducational groups for schizophrenia. Social Psychiatry and Psychiatric
Epidemiology, 42, 909-915.
Snyder, C.R., Ilardi,
S.S., Cheavens, J., Michael, S.T., Yamhure, L. & Sympson, S. (2000). The
role of hope in cognitive-behavior therapies. Cognitive Therapy and Research, 24(6), 747-762.
Spaniol, L., Wewiorski, N.J., Gagne, C. &
Anthony, W.A. (2002). The process of recovery from schizophrenia. International Review of Psychiatry, 14, 327-336.
Spaniol. L. (2008). What would a recovery-oriented program look like? International Journal of Psychosocial Rehabilitation, 13(1), 57-66.
Välimäki,
M., Leino-Kilpi, H. & Helenius, H. (1996). Self-determination in clinical practice: the
psychiatric patient’s point of view. Nursing
Ethics, 3(4), 329-344.
Wiersma, D., Nienhuis, F.J., Giel,
R. & Slooff, C.J. (1998). Stability and change in needs of patients with
schizophrenic disorders: a 15- and 17- year follow-up from first onset of
psychosis, and a comparison between “objective” and “subjective” assessments of
needs for care. Social Psychiatry and
Psychiatric Epidemiology, 33, 49-56.
Zubin, J., & Spring, B. (1977). Vulnerability: A new view of
schizophrenia. Journal of Abnormal Psychology, 86, 103-126.
Zygmunt, A., Olfson, M., Boyer, C.A. &
Mechanie, D. (2002). Interventions to improve medication adherence in schizophrenia.
American Journal of
Psychiatry, 159, 1653-1664.
