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Psychoeducation as Evidence-Based

Practice: Considerations for Practice,

Research, and Policy

Ellen P. Lukens, MSW, PhD

William R. McFarlane, MD

This paper describes psychoeducation and its applications for mental health and health
professions across system levels and in different contexts by reviewing the range of
applications that have appeared in the recent literature. The theoretical foundations of
clinically based psychoeducation are reviewed and the common elements of practice are
identified. Examples of well-defined psychoeducational interventions are presented that
meet criteria for empirically supported psychological interventions. In conclusion, the
broad applications of psychoeducation for health care and mental health practice and
policy at both the clinical and community levels are discussed, and the need for
further evaluation and research is considered. [Brief Treatment and Crisis Intervention
4:205–225 (2004)]

KEY WORDS: psychoeducation, group intervention, evidence-based practice,

randomized trials, brief treatment.

Psychoeducation is among the most effective of This paper examines the research that supports
the evidence-based practices that have emerged psychoeducation as evidence-based practice for
in both clinical trials and community settings. the professions dealing with mental health,
Because of the flexibility of the model, which health care, and social service across system
incorporates both illness-specific information levels and in different contexts by reviewing
and tools for managing related circumstances, the range of applications that have appeared in
psychoeducation has broad potential for many the recent literature. We identified the psycho-
forms of illnesses and varied life challenges. educational examples included in the review by
following guidelines for evidence-based prac-
tices created by the American Psychological
From Columbia University School of Social Work (Lukens),
and Department of Psychiatry, Maine Medical Center Association’s (APA) Task Force on Promotion
(McFarlane). and Dissemination of Psychological Procedures
Contact author: Ellen P. Lukens, PhD, Columbia
University School of Social Work, 622 West 113th Street, (1995). In the Discussion section, the common
New York, NY 10025. E-mail: and unique themes and content across studies
DOI: 10.1093/brief-treatment/mhh019 and populations are identified.
Brief Treatment and Crisis Intervention Vol. 4 No. 3, ª Oxford University Press 2004; all rights reserved.


Psychoeducation is a professionally delivered set the stage for within-group dialogue, social
treatment modality that integrates and syner- learning, expansion of support and coopera-
gizes psychotherapeutic and educational in- tion, the potential for group reinforcement of
terventions. Many forms of psychosocial positive change, and network building (Pen-
intervention are based on traditional medical ninx et al., 1999). They reduce isolation and
models designed to treat pathology, illness, serve as a forum for both recognizing and
liability, and dysfunction. In contrast, psycho- normalizing experience and response patterns
education reflects a paradigm shift to a more among participants, as well as holding profes-
holistic and competence-based approach, stress- sionals accountable for high standards of
ing health, collaboration, coping, and empow- service. Cognitive-behavioral techniques such
erment (Dixon, 1999; Marsh, 1992). It is based as problem solving and role-play enhance the
on strengths and focused on the present. The presentation of didactic material by allowing
patient/client and/or family are considered people to rehearse and review new informa-
partners with the provider in treatment, on tion and skills in a safe setting. These can
the premise that the more knowledgeable the be amplified through specific attention to the
care recipients and informal caregivers are, the development of stress management and other
more positive health-related outcomes will be coping techniques (Anderson et al., 1986;
for all. To prepare participants for this partner- McFarlane, 2002). Narrative models, in which
ship, psychoeducational techniques are used to people are encouraged to recount their stories as
help remove barriers to comprehending and related to the circumstances at hand, are used to
digesting complex and emotionally loaded in- help them recognize personal strengths and
formation and to develop strategies to use the resources and generate possibilities for action
information in a proactive fashion. The assump- and growth (White, 1989).
tion is that when people confront major life Recent mandates at both the federal and
challenges or illnesses, their functioning and international levels have pushed to include
focus is naturally disrupted (Mechanic, 1995). psychoeducation as a focal point in treatment
Psychoeducation embraces several comple- for schizophrenia and other mental illnesses,
mentary theories and models of clinical prac- and are backed by national policymakers
tice. These include ecological systems theory, (President’s New Freedom Commission on Men-
cognitive-behavioral theory, learning theory, tal Health, 2003) as well as influential family
group practice models, stress and coping self-help groups such as the National Alliance
models, social support models, and narrative for the Mentally Ill (NAMI) (Lehman & Stein-
approaches (Anderson, Reiss, & Hogarty, 1986; wachs, 1998; McEvoy, Scheifler, & Frances,
Lukens, Thorning, & Herman, 1999; McFarlane, 1999). Based on an exhaustive review of the
Dixon, Lukens, & Lucksted, 2003). Ecological evidence-based literature on schizophrenia, the
systems theory provides the framework for Schizophrenia PORT (Patient Outcomes Re-
assessing and helping people understand their search Team) study recommended that educa-
illness or experience in relation to other systems tion, support, crisis intervention, and training
in their lives (i.e., partners, family, school, in problem solving be offered to available
health care provider, and policymakers). Under family members over a period of at least 9
this umbrella, psychoeducation can be adapted months (Lehman & Steinwachs, 1998). Best-
for individuals, families, groups, or multiple practice and expert panels corroborated these
family groups. Although psychoeducation can recommendations (American Psychiatric Asso-
be practiced one-on-one, group practice models ciation, 1997; Coursey, 2000; Coursey, Curtis, &

206 Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Psychoeducation as Evidence-Based Practice

Marsh, 2000; Frances, Kahn, Carpenter, Doch- coordination (i.e., easy access and clarity of
erty, & Donovan, 1998), given that remarkably expectation regarding service, medication man-
positive outcomes have been observed in over agement and adherence, and crisis planning),
25 independent studies (Dixon, Adams, & provision of relevant up-to-date information in
Lucksted, 2000; Dixon et al., 2001; McFarlane a timely and flexible manner, attention to
et al., 2003). Several outcomes of psychoeduca- family conflict, communication, loss, problem
tional interventions for schizophrenia are solving, and attention to social as well as
particularly noteworthy and have been dem- clinical needs for the person with illness, along
onstrated across studies (McFarlane et al., with expanded social support for the family,
2003). For persons receiving individual therapy through multiple family psychoeducation and
and medication, or medication alone, the 1-year family support groups (e.g., NAMI) (Dixon
relapse rate ranges from 30% to 40%; for those Adams, & Lucksted, 2000; McFarlane et al.,
participating in family psychoeducation of at 1995; McFarlane et al., 2003).
least 9 months’ duration, the rate is about 15% Psychoeducational approaches also are well
(Baucom, Shoham, Mueser, Daiuto, & Stickle, established as adjunctive treatment for cancer,
1998). Other positive outcomes have been docu- where patients and families are struggling with
mented for patients and for families as well, different forms of challenge. Although persons
suggesting that psychoeducation provides mul- with cancer typically fall into the normal range
tiple benefits. These include decreased symp- in terms of psychological processes, they
tomatology and improved social functioning for inevitably struggle with the anxiety and de-
the patient (Dyck, Hendryx, Short, Voss, & pression following the extraordinary stress
McFarlane, 2002; Dyck et al., 2000; McFarlane associated with the diagnosis and treatment of
et al., 1995; Montero et al., 2001) and improved the cancer (Cunningham, Wolbert, & Brock-
well-being and decreased levels of medical meier, 2000). Numerous randomized studies
illness among family members (McFarlane, over the last two decades have shown signif-
Dushay, Stastny, Deakins, & Link, 1996; Solo- icantly increased quality of life and decreased
mon, Draine, & Mannion, 1996; Solomon, levels of anxiety and distress for persons with
Draine, Mannion, & Meisel, 1996). cancer who participate in professionally led
In schizophrenia, any form of intervention is psychoeducational groups (Cunningham, 2000;
complicated by the symptoms of the illness, Edmonds, Lockwood, & Cunningham, 1999;
which include psychosis as well as functional Meyer & Mark, 1995). There is increasing
and cognitive deficit or distortion, alogia, evidence that psychoeducational and other
inertia, denial, and/or lack of awareness of forms of professionally led support groups can
illness (American Psychiatric Association, have an impact on the longevity of cancer
1994). Patients, formal care providers, and patients as well (Cunningham, 2000; Cunning-
informal caregivers are confronted not only ham, Edmonds, et al., 2000; Fawzy, Fawzy,
by the severe burden of the illness, but by the Arndt, & Pasnau, 1995; Richardson, Shelton,
distorted sense of reality by which it is Krailo, & Levine, 1990; Richardson, Zarnegar,
characterized. To address this multifaceted set Bisno, & Levine, 1990; Spiegel, Bloom, Kraemer,
of challenges, the various psychoeducational & Gottheil, 1989). This reinforces the value and
models for schizophrenia build on a series of importance of emotional support and enhanced
principles that exemplify the paradigm shift to coping in the face of any form of severe illness.
a strengths-based approach to intervention. Families and other informal caregivers of
Key aspects of these approaches include service persons with cancer have been targeted as well.

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 207


In one recent study focusing solely on partners 1998; Chambless & Ollendick, 2001). Broadly
of women with early-stage breast cancer, par- defined, these criteria are grouped as:
ticipants in psychoeducational groups showed
less mood disturbance 3 months posttreatment Category I: established, efficacious, specific
than controls, and the women whose partner interventions, including two rigorous
participated reported less personal mood dis- randomized trials conducted by indepen-
turbance and more emotional support (Bultz, dent investigators;
Speca, Brasher, Geggie, & Page, 2000). These
Category II: probably or possibly efficacious
women also described significantly more stable
intervention, treatment compared with
marital relationships over time, suggesting that
wait-list control; and
the psychoeducational groups served a preven-
tive function. Category III: experimental treatments that do
The number of well-documented evidence- not meet the above criteria for adequate
based studies on psychoeducation as an methodology.
intervention for illnesses as different as schizo-
phrenia and cancer suggests the potential for In addition, the task force determined that
the model. There is significant evidence that Category I interventions should follow a treat-
psychoeducational interventions are associated ment manual or clearly prescribed outline for
with improved functioning and quality of life, treatments and that the characteristics of the
decreased symptomatology, and positive out- sample should be specified (Chambless &
comes for both the person with illness and Hollon, 1998). Nathan and Gorman (1998)
family members as well. extend the characteristics for Category I studies
However, there has been little attempt to to include blind assessment of research subjects
examine the breadth of applications in other by independent raters, specific inclusion and
psychiatric, medical, or clinical settings. The exclusion criteria, up-to-date diagnostic assess-
aim of this paper is to review and discuss the ment, and adequate statistical power.
range of psychoeducational interventions for Studies selected for inclusion in this review
other settings and circumstances using ac- were retrieved through a search of PubMed and
cepted criteria for designating a practice inter- PsychInfo from 1995 until the present. This
vention as evidence based. time period was selected because of increased
attention to selection criteria for evidence-
based practice that has emerged since 1995
Method (Chambless & Hollon, 1998; Chambless &
Ollendick, 2001; Rousanville, Carroll, & Onken,
Our approach is twofold: first, to show the 2001). Key search words included psychoeduca-
breadth of application for psychoeducational tion, psychoeducational groups, randomized trial,
interventions, and second, to include studies control group, clinical trial, controlled trial, and
that follow the criteria for empirically sup- outcome. The intent was to identify studies that
ported psychological interventions devised by would meet criteria for Category I, as described
the Task Force on Promotion and Dissemination above.
of Psychological Procedures (1995). These For the purposes of this review, the following
guidelines have been supported and amplified criteria were used for the selection of published
by other investigators and reported on by studies described as using a psychoeducational
Chambless and colleagues (Chambless & Hollon, intervention:

208 Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Psychoeducation as Evidence-Based Practice

The article focused on one or more inter- (Shelton et al., 2000). A second was excluded
ventions targeting a specific and clearly because a psychoeducational group was used as
defined mental illness, medical illness, or a minimally defined control intervention (Lati-
other form of personal life challenge (e.g., mer, Winters, D’Zurilla, & Nichols, 2003), and
partner abuse). a third because psychoeducation was referred
At least one of the interventions labeled as to as a combination placebo/usual care control
an active treatment was described as with no description as to form or content
psychoeducational in nature, targeting (Kaminer, Burleson, & Goldberger, 2002).
either the family, the person challenged
by the illness or life situation, or both.
Applications for Mental Health
The psychoeducational intervention was
Conditions Other Than Schizophrenia
presented in person (as opposed to online
or solely through written material).
Although reports of randomized trials of
The design of the study involved random psychoeducation for adults coping with schizo-
assignment to the active psychoeduca- phrenia are well represented in the literature,
tional treatment intervention and to adaptations for children and adolescents and for
a control group. (Note that in one in- adults with other serious mental health con-
stance, reports of randomized trials in ditions are just beginning to appear (see Table
process are included in the review as well, 1). Fristad and her colleagues piloted multiple
because they are based on a well-docu- family psychoeducational groups with break-
mented and randomized pilot study [Fris- out sessions for children aged 8 to 11 with mood
tad, Gavazzi, & Mackinaw-Koons, 2003; disorders (including both bipolar disorder and
Fristad, Goldberg-Arnold, & Gavazzi, major depressive disorder/dysthymia as com-
2003]). pared with wait-list controls [Fristad, Gavazzi,
The article provided enough information to & Soldano, 1998; Fristad, Goldberg-Arnold, &
assess the quality of the research design Gavazzi, 2002]). These groups focused on both
and methods and the applicability and parent and child outcomes, including caregiver
relevance of outcome measures. knowledge, increased caregiver concordance
regarding diagnosis and treatment, decreased
The article provided enough information to
expressed emotion in parents and environmen-
assess the nature and extent of the
tal stress for the child, and reduced symptom
psychoeducational intervention, to deter-
severity and duration for the child. The cur-
mine whether psychotherapeutic and
riculum particularly attended to information
educational techniques were integrated.
dissemination, the building of advocacy and
Intervention studies in which the authors
communication skills, both within the family
referred to a seemingly straightforward
and across systems, and strategies for social
educational intervention (i.e., with no
problem solving and symptom management.
psychotherapeutic component) as psy-
Outcomes were positive, with families engaged
choeducational in nature were excluded.
in the psychoeducational groups showing
significantly more knowledge about mood
One article was not reviewed because the symptoms, increased use of support services,
term psychoeducation was referred to in the title and increased reports of parental support by
and abstract but not in the text of the article children, both immediately after and 4 months

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 209


TABLE 1. Mental Health Conditions

Active (PE) Significant

Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Treatment Structure Outcomes

Study Sample/Dx Design Protocol and Duration for PE Commenta

Colom Outpatients Randomized trial: Symptoms, course, 21 sessions Reduced # total Category II.
et al., 2003 diagnosed with PE groups vs. communication, & relapse & # Well-designed study
bipolar I & II disorder. nonstructured coping skills relapses/person.
Conducted in Spain group meetings Increased time to
recurrence; fewer
& shorter
Dowrick Adults with Randomized trial; Relaxation, 12 two-hour Both active Category II.
et al., 2000 depression group PE vs. positive thinking; sessions over 8 interventions Separates PE &
in community individual problem social skills weeks w/class reduced caseness problem solving
solving vs. controls. reunions & improved
N = 452 subjective function.
Problem solving
more well received
Fristad et al., Children with Pilot study; Decrease in symptoms; Multiple family Improved family Category II
1998, 2002 mood disorders randomized improve coping & groups with climate
trial in process communication; break-out groups
stress management; for children/
expanded social supports adolescents.
Late afternoon &
Honey Women Randomized trial: PE Coping strategies 8 sessions Tx group less Category II
et al., 2003 diagnosed with groups for women vs. related to child depressed at
postnatal standard tx. N = 45 care & obtaining posttest &
depression social support; 6-month fu,
cognitive-behavioral controlling for
techniques & antidepressants
TABLE 1 continued. Mental Health Conditions

Active (PE) Significant

Treatment Structure Outcomes
Study Sample/Dx Design Protocol and Duration for PE Commenta

No differences
re social support,
strength of
marriage, or coping
Miklowitz Persons with Randomized trial; PE, with focus on 21 individual Patients showed Category II.
et al., 2003 bipolar disorder & individual PE for communication & sessions w/ family fewer relapses. Well-designed study
family families vs. crisis problem-solving & patient over Longer survival,
intervention for training 9 months greater reduction
Brief Treatment and Crisis Intervention / 4:3 Fall 2004

families. in mood disorder

All patients symptoms & better
received medication. medication
N = 101 compliance
Peterson Women Randomized trial; Review of PE 14 one-hour All active tx Category II.
et al., 1998 with binge therapist-led PE vs. information, stress group sessions showed decrease Small sample
eating disorder partial self-help vs. management, over 8 weeks in binge eating size per cell;
structured self-help vs. homework at posttest group randomization.
wait-list control. Manual based

Psychoeducation as Evidence-Based Practice

N = 61
Rea et al., 2003 Outpatients Randomized trial; PE about bipolar 21 one-hour Patients less Category II.
diagnosed individual family disorder, communication sessions likely to be Well-designed study.
with bipolar I PE vs. individual tx enhancement, problem hospitalized; Manual based
disorder & for patient. N = 53 solving. fewer relapses
their families As-needed crisis over 2 years
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up.
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).

posttreatment. Interestingly, parents reported compared group psychoeducation (12 two-hour

increased positive family interactions, but not sessions over 8 weeks), 6 individual problem-
decreased negative family interaction. solving sessions conducted at home and con-
The authors successfully included children trols. The authors found that the two active
with two different diagnoses (bipolar disorder interventions reduced symptoms and improved
and major depression/dysthymia) in each subjective functioning. The patients particu-
group. This represented an accommodation to larly liked the individual problem-solving
practicality (i.e., ease of scheduling), and sessions. Interestingly, the authors utilized
families appeared to benefit from learning about problem solving as a treatment independent
both disorders. Fristad and colleagues recently of psychoeducation. This is in contrast to most
reported on two randomized trials to test two of the studies reviewed, which specifically
variations on the pilot; one that serves families incorporated problem-solving techniques with-
through eight multiple family psychoeduca- in the definition of psychoeducation.
tional groups, and a second parallel model that In a study conducted in Spain of outpatients
includes 16 individual family psychoeducation diagnosed with bipolar disorder type I and II,
sessions (parent-only meetings alternating with Colom and colleagues (2003) compared the
child sessions in which parents join at the impact of 21 psychoeducational group sessions
beginning and end of the session) (Fristad, with nonstructured group meetings. Partici-
Gavazzi, et al., 2003; Fristad, Goldberg-Arnold, pants in the active treatment were less likely to
et al., 2003). relapse overall, had fewer relapses per person,
Honey, Bennett, and Morgan (2003) tested increased their time to recurrence of symp-
a brief psychoeducational group intervention toms, and had both fewer and shorter hospital-
for postnatal depression, randomly assigning izations. In a relatively small study (N ¼ 53),
45 Welsh women scoring above 12 on the Rea and colleagues (2003) compared outcomes
Edinburgh Postnatal Depression Scale to an for patients involved in 21 individual family
eight-session psychoeducational group or to psychoeducation sessions with standard in-
routine treatment. The partner was not in- dividual treatment. Participants in the family
volved. Although not manual based, the in- psychoeducation sessions were less likely to
tervention followed a prescribed curriculum relapse or be hospitalized over the 2-year
and included coping strategies related to child study. In a separate, larger study, Miklowitz,
care and obtaining social supports, cognitive- George, Richards, Simoneau, and Suddath
behavioral techniques, and relaxation. At post- (2003) randomized 101 individuals with bi-
test and 6 months posttreatment, women in the polar disorder to either 21 individual psycho-
psychoeducational groups showed significantly educational family sessions or crisis
decreased scores on the depression measure, management (2 educational sessions plus crisis
controlling for antidepressant use. However, no sessions as needed). The patients in the
differences occurred in terms of improved psychoeducational treatment showed fewer
social support, marital relationship, or coping relapses overall, longer symptom-free periods,
in analyses of effects for time, group, or Time ! fewer symptoms, and better medication com-
Group interaction. pliance. Both of these studies were manual
Several studies addressed the needs of based, with similar design, method, approach,
persons diagnosed with depression or bipolar and outcome. However, the studies together
disorder living in the community. In a three- cannot be labeled as meeting criteria for
armed study, Dowrick and colleagues (2000) a Category I evidence-based practice because

212 Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Psychoeducation as Evidence-Based Practice

they share an investigator (Chambless & and reaction also showed a significant decrease
Hollon, 1998). for caregivers who received psychoeducation.
Peterson and colleagues (1998) used a psycho- However, there were no significant differences
educational intervention for women with binge between groups for the secondary patient-
eating disorder, comparing it with three other outcome measures.
treatment conditions (partial self-help, struc- In a small study conducted in southern India,
tured self-help, and a wait-list control). This Russell, al John, and Lakshmanan (1999)
was the only study reviewed in which partic- randomly assigned 57 parents of children with
ipants in the psychoeducational intervention intellectual impairment to either an active
did not show superior outcomes over time. psychoeducational group intervention or an
Rather, participants in all active treatments untreated control group. Participants in the 10-
showed a decrease in binge eating immediately session groups showed significantly improved
posttreatment. The authors noted several parental attitude regarding child rearing and
threats to the validity of their study: random- management of the disability immediately
ization that targeted groups rather than indi- posttest.
viduals, small sample size (N ¼ 61), and lack of
follow-up data.
Applications for Medical Illness

Applications for Caregivers of Persons Psychoeducational programs have also been

With Mental Health Conditions devised for medical illnesses, including acute
and life-threatening illnesses other than cancer,
Two studies particularly addressed the needs of as well as more chronic conditions. These
caregivers (see Table 2). Hebert and colleagues programs aim to help both the persons affected
(2003) tested the efficacy of a 15-session series and their caregivers or partner weather both
of psychoeducational groups for informal care- the physical and the psychological impact of
givers of persons with dementia in comparison chronic and acute illness (see Table 3).
with traditional support groups. Randomiza- In one of the cross-national studies identified
tion involved 158 individuals stratified by sex through this review, researchers in Hong Kong
and kinship status at several different sites. The (Cheung, Callaghan, & Chang, 2003) randomly
psychoeducational content in the curriculum assigned 96 women aged 30 to 55 preparing for
was focused on stress appraisal and coping. elective hysterectomy to either individual
Primary outcome measures were blindly as- psychoeducational sessions (information book-
sessed and included frequency and response to let plus cognitive interventions focusing on
behavioral problems among care receivers; distraction and reappraisal) or a control group
secondary measures included patient burden, (information booklet without additional in-
distress and anxiety, perceived social support, formation). Number of sessions, duration, and
and self-efficacy. Immediately following the intensity for the experimental group were not
intervention, those assigned to the psycho- specified and it was difficult to tell how well
educational groups reported significantly less integrated the educational component was with
reaction to behaviors and a trend toward less the cognitive techniques in the psychoeduca-
frequency of reported behavior problems tional intervention. However, women receiving
among the family members with dementia. the active treatment reported significantly
The interaction between behavior frequency lower anxiety and pain and higher treatment

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 213

Brief Treatment and Crisis Intervention / 4:3 Fall 2004

TABLE 2. Caregivers of Persons With Mental Health Conditions

Active (PE) Significant

Treatment Structure and Outcomes
Study Sample/Dx Design Protocol Duration for PE Commenta

Hebert Informal caregivers Multisite Stress appraisal 15 sessions Tx group shows Category II
et al., 2003 of persons with randomized trial; and coping less reaction to
dementia PE groups vs. behavior of patient,
traditional support less frequency of
groups. N = 158 reported problem
stratified by sex behaviors. No
& kinship status difference in burden,
distress & anxiety,
perceived social
support, or self-efficacy
Russell Parents of Randomized trial; Interactive 10 sessions Tx group showed Category II.
et al., 1999 children with PE groups for group PE improved parental Small total
intellectual parents vs. control attitude re child sample size
disability. group. N = 57 rearing & management
Conducted in of disability
southern India
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment.
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).
Psychoeducation as Evidence-Based Practice

satisfaction than those in the control group in eral life satisfaction, and self-efficacy, and
the days immediately postoperative. There was a trend toward improved mental health and
no difference between the two groups in social functioning. No differences emerged
requests for painkillers postsurgery. between the groups either in terms of de-
Two additional models addressed chronic pression and uncertainty regarding future
medical problems, specifically obesity and functioning or on measures from the Medical
generalized pain. Ciliska (1998) randomly Outcomes Short Form (Ware & Sherbourne,
assigned 78 women with obesity to a small- 1992) on physical functioning and general
group psychoeducational intervention (6 to 8 health. It is noteworthy that those who
people per group), to an education-alone group dropped out or refused the active treatment
using a classroom format (16–20 people), or to (8%) appeared to be more affected by pain (i.e.,
an untreated control group. The model empha- unable to sustain employment) than those who
sized problem solving and assertiveness train- enrolled and participated (LeFort & Steinwachs,
ing, with attention to etiology, risks and 1998). This suggests that the experience of
benefits; and the relationship between body severe pain may interfere with willingness or
image and self-esteem. Immediately posttreat- ability to participate in a group intervention.
ment, the psychoeducational subjects showed Olmsted, Daneman, Rydall, Lawson, & Rodin
significantly increased self-esteem, body satis- (2002) assigned 85 adolescent girls diagnosed
faction, and more restrained eating patterns with type I diabetes and comorbid disturbed
compared with participants in either of the two eating patterns and their parents to either
other groups. Outcomes for participants in the a series of six psychoeducational group sessions
education-alone intervention did not differ or a treatment-as-usual control group. The girls
from those in the control group. and parents participated in separate but parallel
Unremitting physical pain is associated with sessions. At 6-month follow-up, the girls in the
depressive symptoms such as distress, hope- active treatment continued to show significant-
lessness, and despair and contributes to dis- ly reduced eating disturbance compared with
ruption in both individual and family the controls.
functioning. To address this set of problems,
LeFort, Gray-Donald, Rowat, and Jeans (1998)
devised a 12-hour psychoeducational model Applications for Other Clinical Settings
adapted from the Arthritis Self-Management and Prevention
Program (Lorig, 1986) for persons confronted
with chronic pain. Curriculum was focused on Programs designed for other life concerns
facts and myths regarding pain, medication, familiar to social service agencies, exclusive of
depression, and nutrition in the context of those directly related to either psychiatry or
problem solving, communication skills, and medicine, have also begun to appear in the lit-
mutual support. The authors randomly as- erature (see Table 4). Gibbs, Potter, Goldstein,
signed 110 individuals diagnosed with chronic and Brendtro (1996) created a manual-based
pain (mean duration of pain, 6 years) to either psychoeducational program for adolescents in-
the psychoeducational groups or a 3-month carcerated in a medium security youth correc-
wait-list control. Immediately posttreatment, tional facility. The psychoeducational groups
the group participants showed significantly met daily and focused on mediation, skills
reduced indicators of pain and dependency, and values enhancement, and peer support.
improved physical functioning, vitality, gen- Adolescents were taught to recognize negative

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 215


TABLE 3. Medical Illness

Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Active (PE) Treatment Structure and Outcomes

Study Sample/Dx Design Protocol Duration for PE Commenta

Cheung Women age 30 Randomized trial; Information plus Not specified Tx group Category II.
et al., 2003 to 35 preparing individual PE sessions cognitive intervention lower Extent and nature
for elective vs. control group (info with attention to anxiety & pain; of PE not defined
hysterectomy booklet only). N = 96 distraction & reappraisal higher tx
of circumstance satisfaction.
No difference in
request for pain
Ciliska, 1998 Women with Randomized trial Education about obesity; 12 sessions over Tx group increased Category II
obesity comparing PE problem solving, 12 weeks; 2-hour self-esteem &
group, education assertiveness training; sessions; 6#8 women restrained eating;
alone, & control. body image work; increased body
N = 78 group support satisfaction
LeFort People with Randomized trial Definitions of pain, 6 weeks, 12 hours Short-term Category II.
et al., 1998 chronic comparing PE myth busting; improvement Well-defined study
physical pain group w/ 3-month cognitive-behavioral of pain severity
wait-list control. techniques; pain & impact, role
N = 110 management; group functioning &
problem solving; involvement, life
communication satisfaction,
skills & mutual support self-efficacy,
decreased dependency.
No difference
re depression,
uncertainty, general
health, or physical
Psychoeducation as Evidence-Based Practice

social behavior both in themselves and among

Manual based
Category II.
their peers and to replace these behaviors
with more constructive and affirmative re-
sponses and actions. In a randomized pilot
study, participants in the psychoeducational
Reduction in eating groups were described as dramatically easier to
manage, with significantly improved social
maintained at skills and adjustment and decreased antisocial

6-month fu

behavior. However, sample size, duration of

for PE

treatment, and time to follow-up were not

In a small randomized trial conducted in
Hawaii, Kubany, Hill, and Owens (2003)
6 weekly 90-minute

assigned 37 ethnically diverse women with

sessions for girls
Separate group
group sessions.
Structure and

both a history of partner abuse and a diagnosis

and parents

of posttraumatic stress disorder (PTSD) to either


an individually based psychoeducational pro-

gram or a wait-list group. Most of the women
(32) eventually completed the program. The
active intervention incorporated 8 to 11 in-
Active (PE) Treatment

dividual one-and-a-half-hour sessions, focusing

on explorations of trauma history, stress man-
agement, monitoring of negative self-talk, as-
PE content,


to control

sertiveness, managing contact with the abuser,


and strategies for self-advocacy and avoid-

ing revictimization. At posttreatment and 3-
month follow-up, 94% of the women no longer
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; fu = follow-up.

met criteria for PTSD. Moreover, they showed

Randomized trial

group w/ tx as
comparing PE

usual. N = 85

significantly reduced depression, guilt, and

shame, and increased self-esteem. In contrast,

those women assigned to the wait-list group

showed no changes in scores for any measure at
the second pretest. Although the sample size
was extremely small, the authors documented
diabetes & disturbed

positive results across ethnic groups, suggest-

TABLE 3 continued. Medical Illness

Adolescent girls

eating attitudes

ing that the themes addressed in the psycho-

and parents
& behavior,

with type I

educational groups (i.e., male dominance and

the status of women relative to men) were
universal issues.
Another study involved groups of partici-
pants from the general population and was
et al., 2002

designed to promote health attitudes and


behaviors regarding nutrition and as a pre-

ventive technique for the development of

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 217

Brief Treatment and Crisis Intervention / 4:3 Fall 2004

TABLE 4. Other Clinical Settings and Prevention

Active (PE) Significant

Treatment Structure and Outcomes
Study Sample/Dx Design Protocol Duration for PE Commenta

Gibbs Antisocial youth/ Randomized PE Strengths-based; Daily meetings, 60#90 Pilot data: Active tx: Clear summary of
et al., 1996 medium-security group vs. control. peer group mediation, minutes; 7#9 youth. 15% recidivism at theory & conceptual
youth correctional Pilot data; N not skills training, anger Duration & leadership 6 mos. & 1 year. model
facility reported management, moral not described Controls: 30% at
education 6 mos.; 41% at 1 year
Kubany Women with Randomized Exploration of 8 to 11 At posttx, 94% did Category II.
et al., 2003 hx of partner individual PE trauma hx, stress hour-&-half not meet PTSD criteria; Small sample
abuse plus PTSD sessions vs. management, sessions reduced depression,
wait-list control. assertiveness, guilt, shame, increased
N = 37 managing contact self-esteem.
with batterer, Wait-list controls
strategies for showed no change
self-advocacy & at second pretest
avoiding victimization
Rocco Adolescent girls Random assignment Focus on normal 9 monthly Tx group showed Prevention-oriented
et al., 2001 in affluent high to PE groups vs. developmental sessions reduced bulimic study; nonclinical
school in Italy; no-group controls transitions, risk factors attitudes, tendency sample
prevention of for eating disorders, to asceticism,
eating disorders social challenge, ineffectiveness, anxiety, &
body shape, & weight fears about maturity
Note: Dx = diagnosis; PE = psychoeducation; tx = treatment; hx = history; PTSD = posttraumatic stress disorder.
Chambless criteria for evidence-based practice (Chambless & Hollon, 1998).
Psychoeducation as Evidence-Based Practice

eating disorders (see Table 4). Rocco, Ciano, and cant others can be identified from this group of
Balestrieri (2001) randomly assigned adolescent studies (see Tables I through IV) and are
girls from an affluent high school in Italy to consistent with those used in the work on
receive either nine monthly sessions in in- schizophrenia and cancer. These include
tensive psychoeducational groups or no in- changes in symptoms (i.e., symptom reduction
tervention. The program targeted normal specific to the targeted illness or situation),
developmental transitions as well as known decreased anxiety and depression (regardless of
risk factors for eating disorders, with attention problem and setting), and less time between
to body shape and weight, social challenges, acute episodes of illness. They also include
and academic achievement. Compared with the increased adherence to and overall satisfaction
controls, participants showed reductions in with medication and treatment, knowledge,
bulimic attitudes, in tendency to asceticism, self-esteem and resources, family/marital cli-
and in feelings of ineffectiveness, as well as mate or adjustment, and quality of life.
lowered anxiety and fears about maturity. However, measures of process—including
attendance, dropout, turnover, training of
facilitators, and fidelity of treatment—cannot
Discussion be so clearly identified. Although these are
more characteristic of evaluation studies than
In reviewing this relatively small number of randomized trials, such data would help to
studies, it is clear that all fall into Category II in inform future studies. In addition, assessment
terms of the APA criteria for evidence-based of resilience and competence, designated as
practice (Chambless & Hollon, 1998; Chambless integral to the strengths-based psychoeduca-
& Ollendick, 2001; Task Force on Promotion tional process, would contribute knowledge
and Dissemination of Psychological Procedures, regarding the unique and irreducible aspects of
1995). None of the studies reviewed would meet the approach (Anderson et al., 1986; Cunning-
the criteria for Category I, because they either ham, 2000; McFarlane et al., 2003). These
are not sufficiently rigorous, have not been include measures of the ability to act and
replicated by independent investigators, or change, willingness to initiate change, appli-
both. However, reviewing the limitations and cation to self-help work, and quality of rela-
strengths of these studies is instructive so tionships with others and everyday experience.
that potential investigators can anticipate the Other limitations can be identified in the
challenges involved in designing and conduct- studies reviewed in terms of both conceptual
ing effective psychoeducational interventions approach and research design. These include
across diagnostic groups and settings. issues regarding sampling strategies, sample
size, and statistical power; measurement (both
process and outcome); analysis; and clinical
Limitations and Strengths of the Studies
definition. As regards sampling, several prob-
The assessment tools and methods that are lems appear. There is almost no variability in
common across the studies identified in this ethnicity within the studies reviewed, with the
paper extend our understanding of how exception of Kubany et al.’s (2003) work on
psychoeducational interventions can be consis- women who have been battered and suffer from
tently evaluated. Several recurring parameters PTSD. In addition, only two of the studies
of measurement for assessing the impact of provide information on independence and
psychoeducation on participants and signifi- blindedness among assessment staff and de-

Brief Treatment and Crisis Intervention / 4:3 Fall 2004 219


scribe inclusion/exclusion criteria for study fidelity of treatment and to ensure potential for
participants (LeFort et al., 1998; Russell et al., efficacy and replication. Some established
1999). investigators have addressed this by providing
Both specificity as to follow-up and efforts to access to their materials through the public
assess sustained impact of the interventions domain. For example, Sherman’s (2003) psycho-
over time are lacking in some of the studies educational curriculum for families of persons
reviewed as well. Work is also needed to assess with mental illness is available on the Internet,
when and for whom psychoeducational inter- and McFarlane’s work on psychoeducational
ventions do not work. Addressing these limi- multiple family groups for schizophrenia is
tations would involve identifying the available through the evidence-based practices
multideterminant and ‘‘optimal’’ measures for project sponsored by the Substance Abuse and
each illness or set of circumstances for the Mental Health Services Administration and the
individual, family unit, individual family Robert Wood Johnson Foundation (Steering
members, and the community. Attending to Committee, 2003).
the profiles of those who reject or drop out of
this form of intervention is also critical.
Summary and Conclusions
Qualitative approaches may be needed to assess
subjective response to intervention, motiva- In summary, this review indicates that psycho-
tion, emotional availability, and readiness to educational interventions have been applied in
process information or participate in a group a wide range of settings across system levels,
intervention (Cunningham, 2000; McFarlane although to date only those addressing schizo-
et al., 2003). phrenia and cancer can be considered evidence
Another factor that interferes with the ability based. A breadth of programs using this flexible
to replicate studies has to do with how the modality have emerged, as professional health
investigators understand and present the clin- care workers have become increasingly aware
ical determinants of psychoeducation in each of the critical role that familial and other
study. Given the breadth of applications cited informal sources of support play in health
in this paper, it is inevitable that the docu- outcome, successful functioning, and quality of
mented interventions would vary greatly in life in several illnesses. As medical and
intensity, duration, and content. However, the psychiatric care have become less contiguous
term psychoeducation is used inconsistently as and all aspects of medical care have become
well, and at least one study referred to the more specialized and fragmented, continuity of
intervention as atheoretical (Bultz et al., 2000). care and knowledge regarding individual sit-
To address these inconsistencies, efforts are uations has become increasingly difficult to
needed to further articulate the common and maintain and coordinate among professional
situation-specific aspects of psychoeducational providers (Lasker, 1997). This has been wors-
curriculum where possible, as well as structure, ened by policy changes in the health care
duration, and organization of content (Cun- environment involving managed care and in-
ningham, 2000; McFarlane et al., 2003). As creasingly consolidated or truncated services
specified in the APA task force on empirically (House, Landis, & Umberson, 1988; McDonald,
supported practice (Task Force on Promotion Stetz, & Compton, 1996; Mechanic, 2002;
and Dissemination of Psychological Procedures, Pescosolido, Wright, & Sullivan, 1995).
1995), access to a well-defined treatment Psychoeducational interventions appear to
manual is essential as a precursor to measuring be sufficiently flexible to circumvent some of

220 Brief Treatment and Crisis Intervention / 4:3 Fall 2004

Psychoeducation as Evidence-Based Practice

the dangers. To date, they have been used implementation, and second, to determine
successfully either as primary or adjunctive acceptance and broad-based integration of the
treatment, as part of a strategic program for pre- approach at the service level (Cunningham,
vention, or as an experiential training tool for 2000; Dixon, Goldman, & Hirad, 1999; McFar-
patients and their families in a range of settings lane et al., 2003).
(Cunningham, Wolbert, et al., 2000; Lukens, Psychoeducation has the potential to extend
Thorning, & Herman, 1999; McFarlane et al., the impact of care provision well beyond the
2003; Thase, 1997). However, additional efforts immediate situation by activating and reinforc-
are needed to fully define psychoeducation at ing both formal and informal support systems
the clinical, community, and professional levels (Caplan & Caplan, 2000; Lundwall, 1996;
as applied to various settings and populations, Pescosolido, Wright, & Sullivan, 1995) and
and to further identify how emerging and state- teaching individuals and communities how to
of-the-art professional knowledge can be in- anticipate and manage periods of transition and
tegrated into such programs. Existing programs crisis. If developed and implemented carefully,
that show preliminary success for conditions following specified guidelines for delivering
other than schizophrenia or cancer must be and documenting evidence-based practices
successfully replicated under rigorous condi- (Task Force on Promotion and Dissemination
tions before they meet the stringent criteria for of Psychological Procedures, 1995), psycho-
evidence-based practice laid out by the APA educational interventions have far-reaching
(Chambless & Hollon, 1998; Task Force on application for acute and chronic illness and
Promotion and Dissemination of Psychological other life challenges across levels of the public
Procedures, 1995). health, social and civic services, and/or educa-
To better establish efficacy and effectiveness, tional systems.
research designed to evaluate the impact of the
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