Should Psychoeducation Be Embraced or Dismissed?

Psychoeducation following trauma is probably useless in preventing posttraumatic stress disorder (PTSD) and may even be harmful, but it shouldn't be abandoned, according to a group of British and Australian experts.

Not everyone agrees, and the resulting discussion—in print—makes for enlightening reading.

“Education is an important but under-examined part of all treatment modalities,” said Robert Ursano, M.D., a professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., who served as guest editor of the winter 2008 issue of Psychiatry: Interpersonal and Biological Processes, where the articles appeared.“ I wanted to provoke some new thinking about psychoeducation, and I think the discussion is a marvelous complement to our developing knowledge of psychological first aid.”

To kick off the argument, Simon Wessely, M.D., and Neil Greenberg, M.D., of the King's Centre for Military Health Research; Jamie Hacker Hughes, Psych. D., head of defense clinical psychology at Britain's Ministry of Defence; and colleagues teamed up with Richard Bryant, Ph.D., of Australia's University of New South Wales.

After conceding the impossibility of satisfactorily defining psychoeducation, they decided the term applies to the provision of information to people about “either what might happen should they be exposed to trauma or, having been exposed, should they develop symptoms.”

For the record, Wessely and colleagues gave several reasons advanced by others in favor of psychoeducation. Supplying information about possible symptoms will make their presence less disturbing should they occur. Pointing out that such symptoms are expectable and not uncommon is reassuring. In addition, psychoeducation may prevent overcatastrophization of the traumatic event and encourage people to seek help. It also encourages self-care and individual empowerment and is inexpensive and easy.

Given all that, however, only one randomized, controlled trial has tested the value of psychoeducation (in civilian victims of accidental trauma), and no evidence of benefit was found, the authors pointed out.

Trials of other treatments for PTSD, such as cognitive-behavioral therapy, have used psychoeducation as a control therapy, but “it is difficult to disentangle the effect of psychoeducation from the nonspecific influences of therapy contact...,” the researchers said.

Wessely and colleagues went on to say that providing information about symptoms in advance might do more harm than good if that activity suggests that victims' later experiences and symptoms will be pathological—citing the example of the now-discredited psychological debriefing following trauma. Even calling an event “traumatic” may engender negative expectations in the minds of victims.

Perhaps information isn't needed to recover from trauma. “Most ordinary people already have well-developed coping skills for dealing with adversity,” they wrote.

More research is needed to tease out what works and what doesn't in psychoeducation, but the goal should be to “[enhance] those mechanisms associated with adaptation and resilience and [minimize] those that may contribute to pathologizing and dysfunction.”

Others agreed with the need for more rigorous research but questioned Wessely and colleagues' reliance on the indirect evidence drawn from studies of other modalities in which psychoeducation is used as a control but is not the prime focus.

Psychoeducation has to be understood and tested on its own terms, as a single variable, to discern its utility, suggested Mark Creamer, Ph.D., and Meaghan O'Donnell, Ph.D., of the Australian Centre for Posttraumatic Mental Health at the University of Melbourne. In addition to well-designed trials of the value of psychoeducation for prevention and treatment, new research should assess the process by which it is delivered, understood, and utilized following trauma.

“We should be asking not just about its role in preventing or treating PTSD, but more broadly about what will be the endpoint of its efficacy,” said Ursano.

While recognizing some shortcomings, others are in no hurry to dismiss psychoeducation.

Steven Southwick, M.D., John Krystal, M.D., and Matthew Friedman, M.D., Ph.D., all affiliated with the Department of Veterans Affairs' National Center for PTSD, disagreed with those dismissive of psychoeducation's value. Southwick and Krystal are also members of Yale's Department of Psychiatry, and Friedman is also affiliated with the departments of psychiatry and pharmacology at Dartmouth Medical School.

They complained that Wessely and colleagues failed to define what they meant by psychoeducation and didn't discuss its role in preventing chronic PTSD or treating the disorder (as compared with its role in the early, acute phase), making it “premature to judge its efficacy.”

“We believe that the potential benefits outweigh the potential risks,” they said, and that psychoeducation plays a useful role in overcoming avoidance, normalizing reactions to trauma, and encouraging help-seeking by victims and their families.

Other commentators suggested that the field would be helped by a highly nuanced type of psychoeducation, tailored to the person experiencing the trauma, the nature of the incident, and a range of cultural factors.

Wessely and colleagues' critique of the subject is both provocative and necessary, given psychoeducation's importance in many areas, including the doctor-patient relationship and public-health interventions on a population scale, said Ursano.

“Does Psychoeducation Help Prevent Posttraumatic Psychological Distress?” is posted at<www.atypon-link.com/GPI/toc/psyc/71/4>.▪