Professional Documents
Culture Documents
S1–S9, 2006
doi:10.1093/schbul/sbl017
Advance Access publication on August 18, 2006
of offense and insecurity can initially only take place in Table 1. Psychoeducation—Effective Therapeutic Factors
the context of cautiously lead, confidential dialog.11 From Supportive Therapy (ST) and Cognitive Behavioral
Therapy (CBT)
In the case of schizophrenic disorders, there are, how-
ever, a large number of individual facts which, despite in-
dividual differences, are generalizable and applicable to Therapeutic Dimensions ST CBT
the majority of patients.12 On account of this, it is imper- Therapeutic interaction (relationship level) XXX XXX
ative for the sake of economy that such fundamental in- Clarification (causal attribution) XX X
formation is passed on as quickly as possible within
Enhancement of coping competence X XX
groups. This simultaneously initiates the group dynamic- (control attribution)
based potential influence of solidarity and a shared
fate, which cannot be achieved within the framework
of one-to-one contacts.13,14 In order that patients and their relatives are empow-
Psychoeducational groups also carry the claim of ered from an early stage onwards in assuming the most
bringing this group dynamic effect to bear in the case constructive role possible in managing the illness, a ‘‘basic
of acute and postacute schizophrenic patients. It is there- competency’’ with regards to comprehension and han-
fore the view of the authors that psychoeducation signi- dling of schizophrenia is indispensable. To this end, psy-
fies a ‘‘specific basic psychotherapy’’ for acute and choeducation entails teaching those affected the ‘‘ABC’’
postacute schizophrenic patients, which capacitates their of schizophrenic disorders and their treatment.
self-competent, well-informed, structured, and successful Preliminary briefing must, in every case, be carried out
involvement in the modern therapeutic options which are by a cautious and empathic therapist, in order on the one
on offer. For this reason, psychoeducation is conceived as hand to counteract dysfunctional processes of causal and
a tool for an optimal combination of the self-help poten- control attribution and on the other hand to profession-
tial of the afflicted and their relatives on the one hand and ally intercept the inevitable feelings of uncertainty and
instances of professional help on the other hand.15,16 In impending demoralization which accompany the com-
the following, a more detailed elucidation of why psycho- munication of specific information concerning schizo-
education constitutes a specific form of psychotherapy phrenic psychoses.18
for schizophrenic patients will be presented. Brochures, books, and videos can be introduced in
a supportive function when it comes to deepening and
consolidating verbally transmitted contents. The employ-
Paralyzing of Empowerment in First Episode ment of various forms of media can, however, never be
Schizophrenia misunderstood as substituting continual dialogical sup-
Most individuals have many natural coping mechanisms port and supervision, at least during the first episode
at their disposal when dealing with the various demands of psychotic manifestation.
of everyday life.15 In the case of first episodes of a severe In the following, reasons for viewing psychoeducation
depression or anxiety disorder, prior experiences of as an independent psychotherapeutic approach for acute
depressive-anxious moods are completely exceeded and and postacute schizophrenic patients will be presented.
most patients, together with their relatives, are not Furthermore, explanations will be offered as to why
able to use their existing behavioral repertoires in order supportive therapy and cognitive behavioral therapy
to counterbalance the suddenly occurring lack of energy, represent 2 successively supplementary therapeutic ele-
interest, and diminished affect. ments, which, in combination with humanistic therapeu-
Because, however, general depressive feelings and fear tic measures, constitute the current typical profile of
are never completely new, a certain level of coping is psychoeducation.14
mostly possible in severe cases of depression, at least
Core Elements of Psychotherapy
in initial stages.
First episodes of schizophrenic disorders, however, In their analysis of psychotherapeutic methods, Grawe
represent a fully new and incomprehensible experience. et al19 isolated 3 pervasive effective factors proving to
The emerging symptoms, including hearing voices, tactile be integral elements of a successful psychotherapy, re-
hallucinations, delusional perception, thought insertion, gardless of, or rather spanning across psychotherapeutic
disorganized thinking, etc., are all completely unfamiliar. schools20 (see table 1).
Accordingly, most patients and relatives react with help- During the clarification phase, fundamental back-
lessness and in an uncoordinated manner. The symptoms ground information surrounding the disorder as well as
which are specific to a schizophrenic disorder are gener- its impact on the patient’s behavior must be successfully
ally so strange and so obscure to the normal citizen that conveyed. From a psychological perspective, the factor
even the individual who has previously proved successful ‘‘causal attribution’’ is at this point of relevance. Concern-
and thrived in life inevitably develops the feeling that they ing the enhancement of coping competence, the acquisi-
just cannot believe what is happening.17 tion of treatment knowledge and practical knowledge
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Psychoeducation
are of foremost importance. Here, psychotherapeutic and its treatment, facilitating both an understanding and
activity must, in the form of ‘‘control attribution,’’ look personally responsible handling of the illness and supporting
to provide tangible assistance when it comes to handling those afflicted in coping with the disorder.
problems which arise.21 The third effective ingredient The roots of psychoeducation are to be found in behav-
comprises a successful ‘‘process of interaction’’ between ioral therapy, although current conceptions also include
elements of client-centered therapy in various degrees.
the therapist and patient; group interactions in the sense
Within the framework of psychotherapy, psychoeduca-
of a ‘‘shared fate’’ also constitute a component of this tion refers to the components of treatment where active
process. communication of information, exchange of information
These 3 fundamental dimensions of psychotherapeutic among those afflicted, and treatment of general aspects of
work represent the basis of psychoeducation. The quality the illness are prominent.34
of patient-therapist relationship when interacting with
Indications for participating in such a psychoeducational
acute and postacute schizophrenic individuals is seen to
group are wide ranging. There are only few mandatory
be of primary importance. It is only when a bridge can
be built to reach these patients, for the most part charac- contraindications, including massive formal thought dis-
terized through their illness by extreme mistrust and an at- orders, manic elevated mood, hearing imperative voices,
titude of skepticism in view of interpersonal relationships, or acute suicidality with generally reduced stress resil-
that the other variables—clarification and enhancement ience. Patients can be integrated within the treatment
of coping competence—can come to bear. Here, and espe- as soon as they are capable of taking part in a group
cially within the initial development of a therapeutic rela- for a period of 60 min. Ideally, only patients suffering
tionship, supportive elements play a central role, whereas from schizophrenic psychoses should participate in the
behavioral therapeutic techniques dominate in the domain group, in order not to evoke unnecessary confusion in
of coping competence enhancement (see table 1). other patients through the schizophrenia-specific infor-
mational content.
Group sittings last approximately 1 hour, take place
Psychoeducation once to twice a week, and consist of between 4 and 16
The term ‘‘psychoeducation’’ was first employed by sessions. Group leaders are in most cases doctors or psy-
Anderson et al22 and was used to describe a behavioral chologists; coleaders can be recruited from all relevant
therapeutic concept consisting of 4 elements; briefing and complementary occupational groups.
the patients about their illness, problem solving training, The superordinate goal can be seen in patients and
communication training, and self-assertiveness training, their relatives acquiring basic competency in order that
whereby relatives were also included. they may reach well-informed and self-competent deci-
Within the Anglo-American realm, psychoeducation sions as to which of the modern therapeutic options—
fulfilled less the function of an independent, self- medicamentous, psychotherapeutic, and psychosocial—are
contained therapeutic method and was viewed more as recommendable and suitable in their own case.
a combination of several therapeutic elements contained As presented in table 2, the formulation of an efficient
within a complex psychosocial intervention.23–28 crisis management plan directed at suicide prevention is
A multitude of studies have demonstrated clear supe- of particular importance. Depressive thoughts of resigna-
riority of psychoeducational family interventions as tion culminating in suicidal consideration are to be
compared with standard treatments.29–33 broached as a sign of postpsychotic depression and on
In light of the evident decline in duration of stay in no account made taboo. Additional administration of
medical institutions of patients with schizophrenia since mood stabilizers, antidepressants, and tranquilizers
approximately 1980 and the simultaneous necessity for together with the parallel involvement of the social envi-
an economic use of therapeutic resources, the demand ronment are displayed as being normal. Rapid taking of
for compact and yet efficient treatment methods grew. preprescribed emergency medication in the case of early
Within this context, from the mid 1980s onwards, an in- warning signs and equipping of the individual with crisis
dependent understanding of psychoeducation began to telephone numbers and points of contact for intervention
unfold in the German-speaking realm. The underly- constitute components of crisis management programs.
ing aim was to create a well-defined, manualized, and In the context of a 2-year follow-up of the Munich
curriculum-orientated therapeutic method, adapted to PIP study (Psychosis Information Project, 35), no differ-
fit the needs of neurocognitively impaired patients with ences were found between an intervention and a control
schizophrenia. The working group ‘‘Psychoeducation group with regards to suicidal thoughts and actions. It
of patients with schizophrenia34’’ has formulated the is the view of the authors that—‘‘state of the art’’—
following definition: psychoeducation does not provoke suicidal ideas reported
The term psychoeducation comprises systemic, didactic- in an outpatient study.35
psychotherapeutic interventions, which are adequate for The psychoeducational procedure described above was
informing patients and their relatives about the illness assessed within the framework of a multicenter study in
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Intervention group 78
Ensuring patients’ and their relatives’ attainment of 80
Control group
‘‘basic competence’’
70
Facilitating an informed and self-responsible handling
of the illness
60
Deepening the patients’ role as an ‘‘expert’’
‘‘Cotherapists’’—strengthening the role of relatives 50
Table 3. Nonspecific Effective Factors of Psychoeducation Table 5. Topics With a Positive Overtone
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Table 7. Important Psychotherapeutic Elements Within which can be understood by patients and their relatives
Psychoeducation and helps them to become experts of their illness.39,40 The
leitmotif of all attempts to educate and illuminate must be
Therapeutic Interaction
Medical textbook–based general standpoint of therapist as
evident in the fact that patients quasi clumsily progress to
orientation guide a higher stage with treatment of each informational unit
Simultaneous respect and esteem for subjective individual and further leave each session feeling encouraged and full
opinions of afflicted of hope. This procedure should not be misunderstood as
Modeling and imitation of therapists a minimization or euphemism of schizophrenic disorders.
Modeling and imitation of patients who are successful
in handling their illness
The cautious introduction of the topic of handicaps
Experience of solidarity in group of patients with caused by the illness, which are often severely protracted
shared fate and unpredictable in terms of duration, also entails
Exchanging experiences with others a great challenge for simultaneously working on feelings
Clarification of grief with the patient. Patients and their relatives are to
Conveyance of basic competence regarding knowledge increasingly gain access to positive thoughts and positive
of schizophrenia conceptualizations of themselves.37 Despite endeavors to
Professional simplification of complex facts
Interpretation of complicated scientific information
remain honest and therapeutically authentic, it clearly
Visualization of key information cannot be the goal of psychoeducation to confront
Interactive style of providing information patients with a merciless picture of all possible negative
Presentation of ‘‘missing links’’ aspects of the disorder from which they suffer. Psycho-
Induction of insight into illness and its requisite education is primarily a form of therapy conveying
treatment measures
Structure and organization into individual therapeutic
reassurance and hope, with the aim of optimally integrat-
measures ing empowerment of those affected with professional
Two-way conveyance of information therapeutic techniques in a working and therapeutic
Transmission of understanding and experiences of alliance.41,42
‘‘enlightenment’’ The take-home-message of psychoeducational pro-
Enhancement of Coping Competence grams must be as follows: schizophrenic psychoses are
Focus on resources and not on deficits induced by biological factors in combination with psy-
Optimized utilization of psychopharmaca
Optimized crisis management behavior
chosocial stress; therefore, they must be treated with
Adequate processing of grief both medication and psychotherapeutic interventions.
Modification of life plan Empowerment of patients can only be successfully devel-
Transformation of patients into ‘‘experts’’ of their illness oped on the basis of sufficient medication and long-term
(knowledge is power) elements of psychosocial treatment.18
Enabling relatives to develop into ‘‘cotherapists’’
Strengthening the protective potential of the family
Realistic Therapeutic Goals in Psychoeducation
access to information concerning appropriate mental The formulation of realistic and coherent therapeutic
health behavior.37 Beginning with the individualized goals is of particular importance for all involved,
experienced-based knowledge of the participants, a com- patients, relatives, and professional auxiliaries.3 Here,
mon denominator with basic textbook medical knowl- the greatest danger within psychoeducation is that de-
edge of schizophrenic disorders and their treatment is spite the narrow time frame in which the intervention
developed. While individual opinions are appreciated is to be carried out, goals are set which are too high
and respected, great value is placed on clearly and com- and indeed unattainable.
prehensibly presenting current scientifically founded ex- The very strength of psychoeducation lies in the delib-
pert knowledge in the form of direct information and erate focus upon patients and their relatives attaining ba-
advice giving.38 It is less the absolute comprehensiveness sic competence in the area of schizophrenic psychoses. In
of transmitted textbook knowledge which is important light of the feelings of helplessness and overload with
and more the construction of a comprehensible concept which many patients and their families are confronted,
of the illness and its treatment (causal and control attri- especially at the onset of the illness, this particular ele-
bution21). In particular, the concrete elaboration of ment is in no way of secondary importance. On the con-
‘‘missing links,’’ which enables lay persons to more fully trary, it is only when a basic understanding of the illness
understand why mental problems can be successfully and its requisite therapeutic measures have been estab-
treated by ‘‘chemical’’ interventions, is of great signifi- lished that more continual and specific therapeutic ele-
cance for increasing functionality.14 In this capacity, psy- ments can be employed. Consequently, as helpful as
choeducation can be seen to serve an ‘‘interpreter’’ the definition of additional therapeutic elements of
function, pursuing the aim of translating complicated Anderson et al22 may be, and as automatic as it is incor-
‘‘technical jargon’’ into common and everyday language, porated into everyday interaction with patients, the prior
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Psychoeducation
development of a certain level of fundamental compe- are in a position to discover the form of treatment which
tence in the area of psychoses is essential in the case of is optimal for their respective phase of illness.
first episodes or at the onset of a reexacerbation. Viewed in this manner, psychoeducation is ascribed
It would not only be unrealistic, but also be, for many a basal psychotherapeutic function, setting the general
patients in an acute or postacute phase, a complete over- course for successful long-term coping in the case of first
exertion if too many elements of communication training, episode patients and adjusting the course once again for
problem solving, training of social competence, etc, were relapsed patients. Through the employment of well-
to be integrated into short-term psychoeducational pro- established elements from supportive and cognitive be-
grams. Significant improvements within these additional havioral therapy, it is possible to draw up a pragmatic
listed areas are only possible within the framework of therapy concept which accommodates the specific needs
more intensive and long-term psychotherapy.10,43,44 of the afflicted patients at the same time as incorporating
This presupposes, however, a certain level of resilience their unquestionably retained resources.47–51
and capacity on the part of the patient. In the case of On the basis of a successful psychoeducational ‘‘com-
family therapy, further logistical preconditions must pulsory-exercise’’ program, including sufficient pharma-
also be fulfilled before therapy over a longer period of cotherapeutic relapse prevention, numerous continuative
time is possible. treatment methods can be built up in the sense of a ‘‘vol-
Like it or not, these preconditions lead to the exclusion untary-exercise,’’ such as supportive therapy, cognitive
of those patients who are particularly severely ill.45 Yet, behavioral therapy, psychosocial support, etc.
psychoeducation pursues the very opposite goal and is Further scientific investigations should attempt to es-
indeed designed to be easily accessible for all patients. tablish which patients adequately profit from a compul-
Psychoeducation should ensure a comprehensive intro- sory-exercise program and which require longer term
duction into the realm of psychoses for patients with a psychosocial measures, ‘‘voluntary exercises.’’ Limita-
first episode of schizophrenia and inform recurrent tions of a compulsory-exercise program on account of cog-
patients of the latest developments in terms of treatment nitive impairments must be explored in order to avoid an
options. overstimulation of seriously ill and vulnerable patients.52
The conscious limitation of sessions to an average of 8, Meanwhile, almost all mental and increasingly more
together with a central focus upon central facts, entails somatic or psychosomatic disorders are accompanied
that these groups are also suitable for the severely ill. by individual psychoeducational concepts. This ensures
The parallel inclusion of relatives in separate groups, that the fundamental right of patients to receive a compre-
which are also temporary and limited to between 6 hensive explanation of their illness and to be given the
and 12 evenings, can help less motivated or occupation- chance of an informed involvement in the drafting of
ally busy relatives be won over for regular visits.30,46 their treatment concept is provided for. This is the foun-
For patients suffering from a less severe schizophrenic dation for achieving optimal collaboration between self-
clinical course, these basic orientation sessions may, to- help powers and empowerment on the one hand and
gether with expedient relapse prevention, be adequate in offers of professional help on the other hand. A more po-
providing stability. tent precondition for the effective treatment of schizo-
In the case of more seriously impaired patients, these phrenic disorders is scarcely imaginable.
groups can be successful in motivating and convincing At the moment, in psychiatric hospitals in Germany,
individuals to opt for involvement in long term and Austria, and Switzerland, psychoeducational groups
more differential therapy. are provided only for 21% of the patients with a schizo-
Chronic patients can, through recurrent integration in phrenic disorder and for only 2% of their relatives.53
this group concept, be sent a sign of hope insofar as they In order to promote the implementation of psycho-
have not been forsaken or abandoned to their fate despite education within the German-speaking countries, the
multiple relapses. Patients thus sense that others believe ‘‘German Society for Psychoeducation’’ (German: DGPE)
that they are able to recover in the face of repeated was founded in the year 2005.
relapses.
Acknowledgments
Standing of Psychoeducation Within a Multimodal
We thank all patients and their relatives, who have
Treatment Concept
participated in our psychoeducational groups and have
Psychoeducation is by no means a rival to continuative given us the opportunity to learn from their
cognitive behavioral therapy or other forms of psycho- experiences and to study their empowerment. We also
therapy in general. On the contrary, psychoeducation thank our colleagues from the psychiatric hospital
is to be seen as a precursor and catalyst for subsequent ‘‘rechts der Isar’’ for their fantastic work over the last
complementary psychotherapeutic and psychosocial 2 decades and for having helped to implement
treatment strategies, such that patients and their relatives psychoeducation into standard therapy. We greatly
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J. Bäuml et al.
appreciate the scientific input and advice provided by 19. Grawe K, Donati R, Bernauer F. Psychotherapie im Wandel.
members of the working group ‘‘Psychoeducation of Von der Konfession zur Profession. Göttingen, Germany:
Hogrefe; 2004.
patients with schizophrenia.’’
Funding for the research and the Open Access 20. Pitschel-Walz G, Bäuml J. Psychotherapie bei Schizophre-
nien: Ergebnisse von Meta-Analysen zur Wirksamkeit. Psy-
publication charges was provided by Josef Bäuml. chiatr. Prax. In press.
21. Seligman MEP. Helplessness on Depression, Development
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