Giving clear, unadorned, unexaggerated and accurate information is a key part of Cognitive approaches to any treatment.

It supports a respectful relationship between KeyWorker and young person - allowing them to share in the decisions about their care. In this sense it relates closely to ideas of Self-efficacy. PsychoEducation is usually understood as an aspect of the Cognitive Behavioural approach to treatment.

Giving advice - not quite the same thing!

A related but subtly different area is Giving Advice.

First assess the current understandings:

Before attempting to introduce new information it is important to be clear about the family's current models of understanding. It is important not to allow this to become a 'question and answer' session, which might justifiably be perceived as positing a "Me: knowledgeable, you: ignorant" axis. Instead, this can be explored using circular questioning, which allows relationships and reflective functioning to be assessed simultaneously:

[To daughter]:"If I asked your father what he thought the cause of this problem was, what would he say?"
[To father]:"Is she good at reading your mind? Did she get that right?"...
"Does anyone in the family have different ideas from these?"..."What are they?"

An important question for the keyworker is whether or not the family have been given a formal diagnosis (which is often far from clear in early onset; quite commonly there will not be a "label" in the early months, if a 'longitudinal' assessment is being made.) Close liaison between the keyworker and psychiatrist is required if this is the case, to avoid the possibility of mixed messages being given.

Psychoeducation about Mentalizing

A specific area of Psychoeducation is when a form of MentalizationBasedWork is starting. For some families it is more helpful to bring out the nature of Mentalizing through the work, but for others some psychoeducation is helpful - a basic explanation of what mentalizing is, how fragile it is, and what it looks like when it is working well is all that is required (see Mentalization, Features of Successful Mentalizing, and Features of UNsuccessful Mentalizing for useful lists on this...)

Introduce new information respectfully, reframing where possible

Presenting new information should ideally take place in such a way as to preserve or emphasise the family's own sense of agency, rather than subjugating it to an external, potentially judgmental, authority figure which enhances the family's sense of passivity, dependence, or guilt and failure.

For instance, presenting the evidence on expressed emotion (EE) in terms of the damaging effects of critical comments, hostility or emotional over-involvement may easily carry a blaming quality with it, to which service-user groups and carers have justifiably objected. The same information can equally well be framed as an opportunity for the family to deploy protective strategies (achieving a low-EE environment) in support of the young person within their midst. This reframing employs a certain amount of normalisation of high-EE behaviour ("Many families in this situation find that the stress leads them to become critical or judgmental - and if they can find ways to cut this down...") in order to remain engaged with the family system.

Activate the individual's or family's curiosity about the information required:

The family is reminded that they are the experts on what it is like to experience a son/sibling in their midst develop a psychiatric illness. Bearing in mind that the family may be quite unused to a formal teaching environment, they are invited to help generate questions that people in their position might want answered.

For instance, they might be asked:

"Imagine we are trying to design a course for families in just your position - what are the questions that you think (with your first hand experience of what it's like to be in the situation) they would want answers for?"

This means of generating questions affirms the family's experience and competence and by positing the existence of other families in similar situations, it reduces the sense of isolation and stigma that families may be overwhelmed by and by introducing the idea of shared experience helping other families, it begins to prepare the family for the potential benefits of multi-family therapy.

Information about a diagnosis:

Producing written material is helpful (see below for sources.) Information 'required' by the family may be drawn out on flip-chart paper to produce a "knowledge tree" with branches representing the major areas, such as 'Definition' ("what is it?"), 'Aetiology' ("Causes" ), Treatment, Prognosis ("The future").

The keyworker might ask the family to elect a scribe for this process. The keyoworker may wish to raise additional areas that have been missed, by asking questions such as, "Would it be helpful for families to know something about...?" These can be sub-divided so that aetiology might have sub-branches concerning genes, environment (including family interactions - EE, illicit drugs). 'Definition', for Schizophrenia, should include 'positive' and 'negative' symptoms, as well as Epidemiology ("How common is it?" - and this can be a helpful way to introduce the notion of Stigma, by emphasising how common the condition is.)

Didactic teaching - the Stress-Vulnerability model of mental illness

This is a useful model of the aetiology of psychosis, and many other mentla illnesses; it accepts the multi-factorial nature of causation in these illnesses. The manifestation of a psychosis in any individual is seen as the end point of a long and varied chain of different factors, reaching back to the moment of conception, each of which multiplies the risk of that individual eventually falling ill with psychosis.

At the beginning of the chain is a genetic vulnerability; a ‘vulnerability factor’ is something that multiplies an individual’s risk of becoming psychotic. Vulnerability to psychosis is certainly coded for by more than a few separate genes, and probably by quite a significant number, so that all of the population would have some genetic vulnerability, but some of the population (about 1 – 2%) has a lot of vulnerability. Following this enhanced risk at conception, an individual’s risk would be further multiplied by pre- or perinatal infections, further multiplied by having a traumatic birth (causing microscopic damage to developing neurons in the brain), further multiplied by experiencing early abuse or deprivation, and in general further multiplied by stress from a wide variety of sources (for instance acculturative stress such as immigrants coming in to very different and often hostile cultures suffer, academic stresses, bullying, etc). Coming on top of all of these multiplied and re-multiplied risks, street drugs are often the ‘straw that breaks the camel’s back’.

Information sources:

For reliable information on SubstanceUseDisorder, refer to the TalktoFrank website. There is some documentation on Cannabis Legal issues here.

For information on Mental Health matters, refer to the Royal College of Psychiatrists website, or Young Minds

Key elements for Psychoeducation in a CBT treatment

• The basic relationship between Thoughts, Feelings and Behaviours.
• The inevitability of some anxiety in life - the necessity of this, even!
• Evidence that the Hypothalamic-Pituitary-Adrenal axis is working properly.
• Evolutionarily very important to have these systems that respond to threat.
• The "Yerkes-Dodson Curve" suggests that some anxiety is required to get the best performance out of humans - just not too much!
• The fact that anxiety, though very unpleasant is not of itself dangerous.

Good practice in psychoeducation:

• Consider the language that you use, and always check back with the young person that they have understood what you have said.
• Avoid checking back in a way that could be taken as critical, or that could trigger unhelpful associations with school settings, where the young person may have had unhappy experiences of "inquisitorial" teaching techniques:
• Try using the young person's own expertise at communicating with their peers as the route in: "I don't know about you, but some of that stuff is very complicated and I know I find it hard to get my head around it and so do many of the young people I work with. I tell you what, say I was one of your mates and didn't have a clue, can you tell me how you would explain it to him, as you will probably have a better way of putting it than I would... what would you say?"
• Use diagrams wherever possible and give them to the young person "...to stuff in that draw you put things that you know you'll never look at, but you might want to be able to find again some day in the future"...