Psychoeducation – A Mental Health Promoting Practice in Schizophrenia

A 40 year old man, police constable by profession, was admitted in the psychiatric unit of a government hospital in Pakistan, with the diagnosis of schizophrenia. Patient was admitted with complains of aggressive behavior, auditory hallucinations, suspicious behavior and irrelevant talking. Patient has had multiple admissions in different hospitals since the onset of the disease in 1994. He was very disturbed with the auditory hallucinations as they were affecting his daily life activities and wanted to know ways to cope with them.

Schizophrenia is a psychiatric illness associated with altered thought processes, distorted behavior, and altered mood with negative and positive symptoms [7]. Schizophrenia affects almost 24 million people worldwide of which 50% people do not receive appropriate treatment and 90% of those belong to developing world [1]. In Pakistan, almost 1.5% of the population, equal ratio of males and females, are affected with schizophrenia [4]. Many patients are readmitted to hospital with relapse of the disease, presumably due to inadequate knowledge about the disease, poor treatment compliance, and recurrent signs and symptoms. Multiple effective strategies using medications, counseling sessions, and education can be employed to assist patients’ live normal lives. Of all interventions, psychoeducation has shown remarkable results in decreasing relapse of disease and in reducing rate of readmissions [2]. The purpose of this review is to discuss the importance of psychoeducation through a nurse-patient psychoeducation model.

According to Kludge et al, psychoeducation “… is defined as systematic, structured, didactic information on the illness and its treatment and which includes integrating emotional aspects in order to enable the participants – patients as well as family members –  to cope with the illness” [13].  Psychoeducation is imparting information to patients and families about a psychiatric illness, and the treatment regimen for rehabilitative purposes [16]. Other terminologies defining psychoeducation are ‘patient teaching’, ‘patient instruction’ and ‘patient education’ [16]. This strategy provides an opportunity to patients and their families to live normal lives with low stress levels, increased knowledge of illness and reduced negative attitudes [7]. It is an evidence based intervention [2] to facilitate the understanding of patients and their families about the nature of illness, treatment, and coping skills required to avoid relapse. Psychoeducation encompasses cognitive, behavioral and therapeutic elements [2] and each element builds on each other throughout the process. Various studies have shown indicate that psychoeducation reduces relapse rates, readmission to hospitals and speed-up recovery of patients. An effective psychoeducation module constitutes empathetic engagement, problem solving, communication skills, social networking, clinical resources knowledge and continuous support [2].

Psychoeducation is a systemic approach encompassing disease, attitudes of patients and families, hospitalization of the patient and knowledge of the nurse. Several models have been proposed for psychoeducation approach; however, Holmes et al, have proposed a nursing model of psychoeducation that integrates the nursing process, and nurse-patient relationship [11].  This model envisions psychoeducation as a component of nurse-patient relationship which may be affected by the attitudes, interests, and beliefs. In addition, psychoeducation may have a direct effect on patient’s post hospital adjustments, readmissions to hospital, number of hospital days and social adjustment [11]. For instance, in the above mentioned case scenario, recurrent readmissions were due to lack of information about hallucinations being a part of a disease process, about coping strategies and about medication incompliance. Psychoeducation has a two-way relationship with ego functioning. Since psychiatric illness is a result of alteration in ego functioning, therefore, the primary motive of psychoeducation is to affect psychiatric symptoms through an effect on the ego functioning thus indirectly influencing patient’s post hospital adjustment. Similarly, ego functioning and psychiatric symptoms can also affect the amount and type of psychoeducation provided. The dual relational arrows between ego functioning and post hospital adjustment also indicate that social adjustment is not only an outcome of ego functioning but can also become an influencing factor [11]. The importance and impact of the nursing psychoeducational model has been emphasized by several studies. A 9-month follow up research conducted in the North Indian tertiary care hospital, comparing routine outpatient care with structured psychoeducation program concluded that structured psychoeducational programs resulted in increased patient satisfaction, reduced disability, and increased family support [14].  Psychoeducation helps patient adjust into their social life and assists in improving social functioning. This was shown in a study conducted on 30 schizophrenic patients who were provided with psychoeducation and were followed after 3 months; the results showed a remarkable improvement in drug compliance and social functioning of these patients after discharge from hospital [8]. A study conducted in Hong Kong compared psychoeducation program (TRIP) with a usual occupational therapy program and found that after a follow up of 12 months the percentage of relapse and re admission of the patients was 13.64% for Psychoeducation and 21.6% for occupational therapy patients [6]. Similarly, another study from Italy found decrease in hospital readmissions, reduced numbers of hospital stay days and improvement in the management of clinical symptoms among patients attending psychoeducation programs [5]. In contrast, [14] another study found that structural psychoeducation did not change relapse rate and did not reduce caregivers’ burden of illness. Nevertheless, Psychoeducation plays an effective role in reducing disease relapse and recurrent hospitalization of patients.

Family psychoeducation is the provision of knowledge and information about psychiatric illness to the family members of a mentally ill patient. Families of psychiatric patients undergo numerous stressors including stigmatization of patient and family name, economic burden, shame, confusion, low self-esteem and may have stressful caregiver’s role. On many occasions, family members of psychiatric patients feel guilty, blame themselves as a primary cause of illness and feel disheartened at the abusive behavior and mood swings of the patients [7].  Inadequate knowledge of the disease process and its treatment results in mishandling of the patient by the caregivers, resulting in disease relapse and recurrent admissions to hospital [7]. A psychoeducation program for caregivers provides knowledge resulting in caregiver’s satisfaction and promotion of healthy life for the patients [7]. Research has shown that family education result in 20% reduction in readmission of patients [13] highlighting the importance of teaching family members. Unfortunately in Pakistan, no specific institution is dedicated to the treatment of patients with schizophrenia except Fountain House in Lahore, which provides many services for schizophrenia patients including family therapy for caregivers and social skills therapy for individual patients [4].

Psychoeducation can be provided through different strategies at individual, group and institutional levels. The most common form of strategy is the class format (discussion method) where patient and the family members of a patient are provided teaching.  Varcarolis & Shoemaker [17] have suggested the formation of several groups of nurses for specific objectives of psychoeducational programs for patients and their families. The groups included are:

• Medication education group.
• Sexuality group
• Dual diagnosis group.
• Multifamily group.
• Symptom management group.
• Stress management group.

Another method is the formation of groups of patients and families with same diagnosis and helping them to narrate their stories and share methods employed taking care of patients [15]. On institutional level, training provided to psychiatric staff and initiation of specific programs can be very useful. A report on Pakistan earthquake by International Red Cross and Red Crescent societies stated that staff at Abbotabad hospital were trained in psychoeducation through psychosocial modules which ultimately helped people, affected with earthquake, cope with their mental stress and distress [3]. IN addition to the use of psychoeducation in specific natural disasters, different psychoeducational programs such as TRIP (Transforming Relapse and Instilling Prosperity) program [6] and PRP (Program for Relapse Prevention [9]) can be launched to promote and implement psychoeducation.  Apart from these traditional methods, an innovative method of ‘psychoeducation through radio’ was also practiced in the Jammu Kashmir by ‘Médicins Sans Frontières’ (MSF) where information about the causes of stress, symptoms of stress and coping strategies was provided [10].

The case scenario mentioned above is a practical example of need for psychoeducation on individual basis. After assessing the patient’s need for dealing with hallucinations, a teaching plan can be prepared. The teaching plan may have two main objectives

• Definition of hallucinations
• Strategies to manage hallucinations.
• Strategies to manage hallucinations include:
• Distraction by talking with someone else or getting busy in some work.
• Saying ‘STOP’ to the voices.
• Using earplug in the ear (left ear dominant in the patient)
• Practicing relaxation exercises like deep breathing (practical demonstration on the bed side).
• Listening to Quranic versus or any religious speeches.
• Drug compliance and avoidance of alcohol, and cigarettes (patient was a chain smoker since 30 years).

The method of class format (mentioned in relevant strategies section) with patient and family members may also be utilized to provide symptom management psychoeducation. The patient may be provided with a pamphlet containing a pictorial view of all the strategies for sustainability and remembrance. The patient should be evaluated immediately and after some time for integration of psychoeducation techniques in daily living via continuous follow ups.

Psychoeducation is the provision of education to patients with psychiatric illness and their family members about the disease process, treatment options and coping strategies. It is an integrated component of nursing and the main goal is to reduce hospitalization and improve social functioning of patients. Varying strategies can be employed to practice psychoeducation at individual, group or institutional levels.

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