INTRODUCTION:

Psycho education is the globally applied supportive and informative service, which is specially designed to provide factual information about mental illness to the psychiatric patients and their caregivers. It is offered by mental health professionals in order to modify and enhance their existing knowledge about mental illness and to make them able to cope more effectively in realistic way with the consequences of mental illness like schizophrenia. It uses educational techniques, methods, and approaches to aid in the process of recovery from the disabling effects of mental illness or as an adjunct to the treatment of the mentally ill person and/or their caregivers.¹ It has established its efficacy and effectiveness as an evidenced-based practice in improving compliance, relapse prevention, and positive effect on symptoms of schizophrenia.²

According to the guidelines of American Psychiatric Association psycho educational interventions belong to a standard therapy program in acute and post acute phases of patients with schizophrenia. In the Cochrane analysis of Pekkala et al. psycho educational interventions were accompanied by a higher level of compliance, lower rate of relapse and improve psychological status.²

Psycho education is a professionally delivered treatment modality integrating and synergizing psychotherapeutic and educational interventions. Such education can be in the form of information and diagnoses and treatments (psycho information) and/or teaching psychological skills to reduce symptoms and improve functioning. Psycho education is used to help remove an individual’s confusion, anxiety, and other barriers surrounding a psychiatric diagnosis, which may obstruct progress in treatment. Psycho education is often confused with psychotherapy (Friedberg and McClure, 2002). However, the main difference between the two is psycho education deals with the acquisition of information and/or skills while psychotherapy involves the actual application of information/skills to a person’s specific life circumstances inside and outside of therapy (Friedberg and McClure).³

History:

The concept of psycho education was first noted in medical literature, by John E. Donley in his article “Psychotherapy and re-education” in The Journal of Abnormal Psychology, in 1911.^4.5 Thirty years later in1941, Brian Tomlinson introduced the word to the medical community with the title of his book, “The psycho educational clinic” in New York. American researcher C. M. Anderson popularized the term “psycho education” in 1980 with her work on the treatment of schizophrenia. Anderson described regarding behavioral therapeutic concept comprising of 4 elements; briefing the patients about their illness, problem solving training and self-assertiveness training, where patient’s relatives were also included.¹

Although, the current concept of psycho education also include elements of client-centered therapy in various levels but the origin of psycho education are to be found in behavioral therapy.⁶ Mc Gill and Lee 1986 traces the evolution of the psycho education constructs as applied to this population and identify the underlying elements that support it. These includes 1) family involvement and support, 2) an emphasis on adherence, 3) specific information about illness, 4) strategies for symptom management, 5) involvement of caregivers in recognition of early signs of decompensation to bring down the relapse, 6) access to crisis intervention, 7) problem solving and stress management strategies, 8) strategies to build family acceptance, and 9) continuity of services and care.⁷

At the beginning of the 20th century, information about mental illness and how to cope with it was introduced via books or bibliotherapy (Pardeck, 1994). Bibliotherapy derives from the Greek words for book (biblio) and therapy (therapeia) and has been used as a therapeutic method since ancient Greece (Pardeck, 1998). Since the 1990’s there have been a number of different self-help approaches to working with youth and adults, such as the Internet, books, magazines, and other reading material. Psycho education is one type of bibliotherapy professionally delivered by therapists, rather than books alone. Its development has its roots in the concept of expressed emotion (EE), which refers to the critical, hostile, and emotionally over involved attitude relatives have toward and communicate (either verbally or nonverbally) to other family members.⁷ Psycho education was first used with families of adults with schizophrenia (see Goldstein and Miklowitz 1995 for a full review), it has since been applied to families containing members with depression (Holder and Anderson, 1990), bipolar disorder (Honig, Hofman, Rozendaal and Dwingemans, 1997; Miklowitz and Goldstein, 1990) or any mood disorder (Clarkin, Carpenter, Hull, Wilner and Glick, 1988). In contrast to adult psycho education programs, there have been relatively few programs for youth. Dreier and Lewis (1991) first developed a program for caregivers of psychiatrically hospitalized children and Sheridan and Moore (1991) for caregivers of outpatient adolescents/young adults with schizophrenia, followed by Brent, Poling, McCain, and Baugher (1993) who developed a program for families of adolescents with mood disorders. ⁸

Importance of psycho education for caregiver of schizophrenia:

Caregivers of individuals with schizophrenia often experience negative thoughts. The purpose of psycho education is to increase knowledge and understanding of their illness and treatment. It is supposed that increase knowledge enables people with schizophrenia to cope more effectively with their illness. It also promotes positive attitudes such as empathy and affective support.

MATERIALS AND METHODS:

A study was conducted by Cohan et al. (2008) to assess the state of the art regarding family psycho education and to form a concurrence regarding the next steps to increase family involvement. In this study, psycho education was found to reduce the level of expressed emotion of the caregivers of schizophrenic patients and it decreases relapse rates of individual with schizophrenia.⁷

A randomized controlled experimental study was done by Ozkan B, Erdem E and Zarasiz G (2010) to determine the effect of psycho education on primary caregivers of the schizophrenic patients. They have taken 62 caregivers of schizophrenic patients, assigned to a no. of 32 participants in experimental group and a no. of 30 participants in control group. The study results revealed that psycho education decreases in family burden, emotional expression and depressive symptoms for their caregivers and was a support for the family in the patient care.²

Another study was conducted by S Mc Williams et al. (2012) on “Schizophrenia: A Five- Year Follow-Up of Patient Outcome Following Psycho-Education for Caregivers”. This study was a five year retrospective case-control follow-up of an original cohort of 63 patients and their 101 caregivers who completed a six week Caregiver Psycho education Programme (CPP) for schizophrenia and psychosis. The study showed that patients whose caregivers attended six week psycho education course had a significantly better outcome than controls and also revealed that patients whose caregivers learned CPP had a significantly smaller number of relapse (p <0.01), longer time to relapse (p <0.01) , shorter length of stay during their first relapse (p <0.01) and smaller number of bed days over five years (p <0.01).⁹

An experimental study was done by Verma PK, Walia TS, Chaudhury S, Srivastava S to assess the efficacy of family psycho education intervention on the caregivers of schizophrenia patients with respect to their perceived quality of life. A total of 30 caregivers of male schizophrenia patients were selected by purposive sampling technique and were divided into experimental and control groups. Family psycho education was given on twice in a month for 6 months to the experimental group. And baseline assessment was done by WHOQOL BREF tool. The result showed that a significant improvement in overall quality of life scores was observed in experimental group caregivers compared to control group caregivers where no such intervention was provided.⁶

Sharif F, Shaygan M, Mani A (2012) conducted a study in Shiraz, Iran to explore the effectiveness of family psycho education in reducing patients’ symptoms and on family caregiver burden. A total of 35 caregivers were selected randomly in experimental group and 35 in control group. Each caregiver attended 10 sessions in five weeks (2 sessions in each week). The study suggested that need based short -term psycho educational intervention for family members of Iranian patients with schizophrenia disorder may improve the outcomes of patients with their families.³

A pre experimental study was done by Britto JG, Ramachandra to assess the effectiveness of structured teaching programme on knowledge regarding schizophrenia relapse prevention among care givers in National Institute of Mental Health and Neurosciences. A total no. of 46 care givers were selected and 30 of them were selected on the lottery method for the analysis of the study scores. The educational programme was conducted in groups in six sessions. This study revealed that a short educational programme would be beneficial for the care givers who play an important role in the life of the patients with schizophrenia and could capably reduce the number of relapses.¹⁰

A Non- experimental descriptive study was undertaken by Nirmala V, latha GM to assess the burden, social support and family wellbeing among caregivers of mentally ill patients at Institute of Mental health at Erragadda, Hyderabad. A total of 60 caregivers of mentally ill patients were taken by using non-probability convenient sampling technique and a structured interview schedule was prepared to assess the burden, social support and family wellbeing among caregivers. The study showed that the best way to prevent Mental illness is to create awareness on preventive, promotive and curative aspect of mental health and adopting healthy measures to overcome stress.¹¹

An evaluative study of video assisted teaching module (VATM) on homecare of schizophrenic patients developed for primary caregivers at Mangaluru was done by Balasubramanian N, Shetty AP, Rao TSS (2017). A true experimental research design with an evaluative approach was used for the study. Samples were selected by using simple random sampling technique and assigned as experimental and control group by means of lottery method. The researcher prepared a Video Assisted Teaching Module on homecare of schizophrenic patients to evaluate its effectiveness. The data was collected by the structured closed ended knowledge questionnaire on home care (KQHS), caregivers attitude scale on homecare of schizophrenics (CASHS) and caregivers skill scale on homecare of schizophrenics (CSSHS). The study showed that VATM is highly effective to improve the knowledge, attitude and skill of primary caregivers on homecare of schizophrenic patients.¹²

Another study was conducted by Sharma L to determine the caregivers’ burden as measured by caregivers burden, social support, family well being and find the relationship between care giver burden and social support, care giver burden and family well being and social support and family well being. By using purposive sampling technique 50 samples were collected. Study concluded that caregiver burden had a significant negative relationship as social support and family wellbeing decreased, caregiver burden increased. But there was a positive relationship between social support and family wellbeing, family wellbeing increased with increased social support.¹³

Sam S, Appavu S, Chellappan S conducted a study to assess the effect of counseling on level of burden and coping among caregivers of terminally ill cancer patients admitted in selected hospital in Kanyakumari District. Pre-experimental one group pretest post-test design was adopted. Data was collected from 30 caregivers of terminally ill cancer patients by using purposive sampling technique. Pretest was done by using Zarit burden scale and caregivers coping scale. Three sessions of counseling was given on alternative days. Post-test was done on 7th day. Study revealed that the counseling program helps to reduce the level of burden and improving the coping among primary caregivers of terminally ill cancer patients.¹⁴

Another study was done by Choudhary RD, Dave K to determine the effectiveness of comprehensive educational intervention (CEI) on stress and coping among caregivers of hospitalized psychiatric patients. A qualitative pre experimental design was used. A total of 100 caregivers of hospitalized patient were selected by using convenient sampling technique. Pre test assessment of level of stress and coping was done and CEI was given to all caregivers. Posttest assessment of stress and coping level was done after one week. Study revealed that CEI was significantly effective to reduce level of stress and improve coping skills among caregivers of hospitalized psychiatric patients.¹⁵

Jiju C L, Alka P, Suresh, David, Sushant, Darshan et al conducted a study to assess the level of burden among caregivers of mentally ill patients in psychiatric hospital. A standardized tool on burden developed by Zarit et al in 1980 is a 22- item scale used to measure feelings of burden experienced by individuals caring for patients with mental illness. A sample of 60 caregivers were taken from selected hospitals and it was found that 58% of caregivers were having moderate level of stress.¹⁶

Vivitha AS conducted a study to evaluate the effectiveness of structured teaching programme on expressed emotions and knowledge regarding relapse prevention among caregivers of patients with schizophrenia in a selected hospital, Salem. The non probability purposive sampling technique was used to select the 30 caregivers from Sri Gokulam Hospital. Expressed Emotions was assessed by using Level of Expressed Emotions Scale (LEE) and knowledge regarding relapse prevention was assessed by using structured self reporting questionnaire. The study indicated that the structured teaching programme was effective in improving the level of knowledge regarding relapse prevention among caregivers of patients with schizophrenia. This study concluded that structured teaching programme was effective in increasing the knowledge regarding relapse prevention and decreasing the expressed emotions among caregivers of patients with schizophrenia.¹⁷

Kumari A, Das K conducted a study on effectiveness of ‘Psychological Intervention’ in reduction of stress in caregivers of the patients admitted in selected ICU’s. After getting consent, pre intervention stress level of the caregiver using Modified caregiver strain index and Life event scale is done. After assessing stress of the caregiver ‘Psychological intervention’ was given for 4 days. Every day 20-25 minutes intervention was given to each caregiver for 4 consecutive days. On the completion of 4 days, post intervention stress level of caregivers was assessed using Modified caregiver strain index. Analysis was done using the SPSS version 16.0 for windows. In the present study ‘Psychological intervention’ to the caregivers within 24 hours of admission of the patients in Intensive care unit helped in reduction of stress significantly in the interventional group.¹⁸

Another study was done by Heydari M, Razban F, Mirzaei T, Heidari S to determine the effect of problem oriented coping strategies training on quality of life of family caregivers of elderly with Alzheimer. In this randomized clinical trial 72 caregivers were chosen by purposive sampling technique and were divided randomly into control and experimental groups. Before the intervention, participants’ quality of life was assessed by SF36 quality of life questionnaire. Eight sessions of educational intervention were held for the experimental group. Information was recollected after two weeks of the intervention. The study concluded that the problem-oriented coping strategies training can enhance most dimensions of quality of life of caregivers and such education can be effective on their lives.¹⁹

RESULT:

It has been estimated across studies that 30-85% of adults with schizophrenia have a family member as a caregiver. Caregivers of schizophrenia patient feel low self esteem, hopelessness and helplessness. As a result of these negative thoughts, their likelihood of depression may increase in the caregivers of the patient.

CONCLUSION:

Schizophrenia affects not only the patients’ life but also equally affect their caregivers. Between 50-80% of patients with schizophrenia live with or have regular contact with family members and rely on caregivers. Hence, there is a need to social support to such vulnerable groups who are always at high risk to develop emotional problems.

REFERENCES:

1. Bauml J, Frobose T, Kraemer S, Rentrop M, Gabriele PW. Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia bulletin. 2006 Oct; 32(1): 51-9. Available from https://doi.org/10.1093/schbul/sbl017.

2. Ozkan B, Erdem E, Ozsoy SD, Zarasiz G. Effect of psychoeducation and telepsychiatric follow up given to the caregiver of the schizophrenic patient on family buden, depression and expression of emotion. Pub J Med Sci. 2013 Sep-Oct ; 29 (5): 1122-7.

3. Sharif F , Shaygan M, Mani A. Effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patient with schizophrenia in Shiraz, Iran BMC Psychiatry. (2012); 12(48). Available from https://doi.org/10.1186/1471-244X-12-48.

4. Xia J, Merinder LB. Psycho education for schizophrenia. Cochrane Schizophrenia Group. Available from https://www.ncbi.nlm.gov.

5. Bulut m, Arslantag H, Dereboy IF. Effects of psycho education given to caregivers of people with a diagnosis of schizophreni. Issues in mental health nursing. 2016 Nov; 37(11): 800-10.

6. Verma PK, Walia TS, Chaudhury S, Srivastav S. Family psycho education with caregivers of schizophrenia patients : impct on perceived quality of life. Industrial psychiatric journal. 2019; 28 (1): 19-23.

7. Cohen AN, Glynn SM , Murray AB, Fischer EP et al. The family forum: directions for the implementation of family psycho education for severe mental illness. Psychiatry Serv. 2008; 59(1): 40-48.

8. Holmes H, Ziembe J, Evans T, Williams CA. Nursing model of psycho education for the seriously mentally ill patient. Issues in mental health nurs.1994; 15 (1): 85-104.

9. S Mc Williams et al. Schizophrenia: a five- year follow up of patient outcome following psycho- education for caregivers. Eur psychiatry. 2012 Jan.

10. Josephine Gracia Britto, Ramachandra. Relapse Prevention among Caregivers of Patients with Schizophrenia. Asian J. Nur. Edu. and Research 4(1): Jan.-March 2014; Page 140-144.

11. Nirmala V., G. Madavi latha. Assess Burden, Social Support, and Family Wellbeing among Caregivers of Mentally Ill Patients at Institute of Mental Health, Erragadda, Hyderabad, and Andhra Pradesh. Asian J. Nur. Edu. and Research 1(2): April-June 2011; Page 64-67.

12. N. Balasubramanian, Asha P Shetty, T. S. Sathyanaraya Rao. An Evaluative Study of Video Assisted Teaching Module (VATM) on Homecare of Schizophrenic Patients developed for Primary Caregivers at Mangaluru. Asian J. Nur. Edu. and Research.2017; 7(1): 53-60. doi: 10.5958/2349-2996.2017.00012.

13. Leena Sharma. A Descriptive Co-relational study on Burden, Social Support and Family Wellbeing among Caregivers of Mentally Ill Patients in Mansik Aarogayashala , Gwalior (M.P.). Asian J. Nur. Edu. and Research.2017; 7(2): 228-230. doi: 10.5958/2349-2996.2017.00047.7.

14. Steffy Sam, Santhi Appavu, Sheeba Chellappan. Effect of counselling on burden and coping among caregivers of cancer patients with Terminal illness. Asian J. Nursing Education and Research. 2019; 9(3):331-336. doi: 10.5958/2349-2996.2019.00071.5.

15. Ruchika Duggal Choudhary, Dr. Koushal Dave. Effectiveness of Comprehensive Educational Intervention on Stress and Coping among Caregivers of Hospitalized Psychiatric Patients. Int. J. Nur. Edu. and Research. 2020; 8(2):226-230. doi: 10.5958/2454-2660.2020.00049.6

16. LijiJiju Chacko, Alka Pawar, Suresh, David, Sushant, Darshan, Yojana, Shweta, Ashwini. Assessment of Burden among Caregivers of Mentally Ill Patients in Psychiatric Hospital. Int. J. Nur. Edu. and Research. 2018; 6(4):371-373. doi: 10.5958/2454-2660.2018.00090.X

17. A. Sahaya Vivitha. A Study to Evaluate the Effectiveness of Structured Teaching Programme on Expressed Emotions and Knowledge regarding Relapse Prevention among Caregivers of Patients with Schizophrenia in a Selected Hospital, Salem. Int. J. Nur. Edu. and Research. 2017; 5(1): 01-05. doi: 10.5958/2454-2660.2017.00001.1.

18. Aarthi Kumari, Karobi Das. Effectiveness of ‘Psychological Intervention’ in reduction of stress in caregivers of the patients admitted in selected ICU’s. Asian J. Nur. Edu. and Research 5(3): July- Sept.2015; Page 337-340. doi: 10.5958/2349-2996.2015.00069.5

19. Maryam Heydari, Farideh Razban, Tayebeh Mirzaei, Shahin Heidari. The Effect of Problem Oriented Coping Strategies Training on Quality of Life of Family Caregivers of Elderly with Alzheimer. Asian J. Nur. Edu. and Research.2017; 7(2): 168-172. doi: 10.5958/2349-2996.2017.00034.9

Received on 11.07.2020 Modified on 18.10.2020

Asian J. Nursing Education and Research. 2021; 11(2):231-235.

DOI: 10.5958/2349-2996.2021.00055.0