November 29, 2012

Psychoeducation

Psychoeducation is a core feature of cognitive-behavioural therapy--and any good therapy. The term refers to information that a therapist provides a patient about the patient's symptoms or disorder, about the therapy model, and about how treatment will proceed, among other things. A lot of psychoeducation occurs in the first few therapy sessions, but psychoeducation also involves explaining new concepts and providing a rationale for in-session exercises or homework assignments over the entire course of therapy.

As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.

I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!

My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:
  • For patients with panic attacks: It's normal to think you're going crazy or to think you're having a heart attack during a panic attack. In fact, both are listed as panic symptoms in the DSM.
  • For patients who feel guilty about being depressed: It's normal to feel guilty when you're depressed. In fact, guilt is one of the DSM criteria for diagnosing depression.
  • For patients who fear their depression is making them stupid: Poor memory and difficulty concentrating are listed as DSM diagnostic criteria for depression.
  • For patients with generalized anxiety: Worry and anxiety are maintained by intolerance of uncertainty.
  • For depressed or anxious patients: Depression and anxiety can be maintained by beliefs about depression and anxiety (e.g., anxiety makes me productive; only stupid people are happy).
  • For patients with insomnia: Many cases of insomnia can be cured through simple sleep hygiene (e.g., always going to bed at the same time; not eating, drinking, or exercising right before bed; eliminating noise and light in the bedroom).
  • For mindfulness meditation clients: Meditating doesn't mean clearing your mind of all thoughts. Practicing mindfulness doesn't mean you'll be Zen all the time.
  • And my favourite, for everyone: Thoughts aren't facts. Not everything you think is true. 
The examples listed above are everyday facts for cognitive-behavioural therapists, but gifts for patients. It's like when your dentist explains to you that exposed roots are common and are often caused by overzealous brushing; when your lawyer informs you that you need your neighbour's consent to build a fence on your shared property line; or when my athletic therapist told me that imbalances in muscle strength can produce knee pain. The gift is information that produces understanding and/or relief and/or a direction for moving forward (e.g., get a soft-bristled toothbrush; set up a meeting with your neighbour; stop exercising late at night; consider ways of increasing your tolerance for uncertainty). 

* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.

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