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Psychoeducational groups

Our patients value groups
With the development of psychoeducation over the past few decades, the field of psychiatry has been moving away from a “doctor knows best” approach to treatment. As is true in general medicine, patients with psychiatric disorders who educate themselves about their illness and treatment options will be in the best position to obtain optimal care. Results of a patient survey we conducted at Menninger were consistent with this trend.¹

We asked inpatients to indicate their preferences regarding what kind of group interventions they would like to receive. From 41 interventions, they ranked “education about treatment” first and “education about my illness” third. Consistent with these preferences, we have adopted an especially ambitious approach to patient education at The Menninger Clinic. We aspire to share all the knowledge we possibly can. At the same time, we strive to continually expand our knowledge together with patients and to make that knowledge available to our professional colleagues and to the wider public.

Evolution of Psychoeducation
Psychoeducation began as a family-focused intervention in the treatment of schizophrenia, emphasizing the biological basis of the disorder with the intent of reassuring family members that they are not the cause of the disorder while helping them to understand how patterns of interaction in the family may influence the course of the illness. Having demonstrated success in the treatment of schizophrenia, psychoeducational approaches were subsequently extended to the treatment of a wide range of others disorders, including depression, bipolar disorder, obsessive-compulsive disorder, chemical dependency, eating disorders, borderline personality disorder and trauma-related disorders.

Since their inception as family-focused interventions in schizophrenia, psychoeducational approaches have been extended not only to a broader range of disorders, but also to a primary focus on educating the individual patient. Clinicians at Menninger joined the field some decades ago in conducting psychoeducational workshops for persons with schizophrenia and their family members, and we continue to conduct family workshops devoted to a wide range of psychiatric disorders. At the same time, we have been pioneering a patient-centered psychoeducational program tailored to our treatment philosophy. Sensitive to the results of our survey of patient preferences, we aspire not only to educate patients about a range of psychiatric conditions, but also to help them understand how we think about treatment.

Employing Attachment Theory
Guided by research being conducted in the Menninger Child and Family Program, we are applying concepts from the field of attachment theory in our patient education. Attachment theory, developed by John Bowlby, focuses on the development of close emotional bonds, beginning in caregiver-infant relationships. Bowlby emphasized that attachment relationships continue to be of paramount importance throughout life, because attachment relationships play a primary role in regulating emotional distress by providing comfort and a feeling of security. Consistent with attachment theory, extensive research demonstrates the importance of social support in healing from psychiatric disorders and in wellness. Thus we have developed a psychoeducational group that focuses on maximizing support in different kinds of relationships, ranging from friendships to relationships with therapists.

Inspired by the work of British psychoanalyst Peter Fonagy, PhD, who has led research in the Menninger Child and Family Program, we are also pioneering psychoeducation revolving around the concept of mentalizing—understanding mental states in oneself and others. Mentalizing in relationships entails each person having the other person’s mind in mind, and mentalizing begins developing in infancy by virtue of the caregiver’s having the infant’s mind in mind. Although mentalizing covers a lot of territory, thinking about feelings in oneself and others is central, and the capacity to think about feelings while in the midst of strong emotions—what we call mentalizing emotionally—is a crucial skill our treatment endeavors to foster. Mentalizing is the key to emotion regulation and stress management, as well as to maintaining healthy relationships with others.

Dr. Fonagy and his colleagues are demonstrating how secure attachment relationships are conducive to developing mentalizing capacities, and this principle is guiding our treatment efforts. Believing that patients will make best use of treatment if they understand our treatment philosophy, we have developed a specialized psychoeducational group devoted exclusively to exploring the concept of mentalizing. We discuss how mentalizing contributes to resilience in the face of stress; how problems in mentalizing play a role in psychiatric disorders such as depression, anxiety, posttraumatic stress disorder, and personality disorders and how various aspects of treatment—ranging from clinical rounds to individual, group and family therapy—foster mentalizing capacities.

Groups foster a spirit of inquisitiveness
Ideally, we strive to foster inquisitiveness about psychiatric disorders among patients as well as staff members. Sometimes we think of these groups as seminars in which we engage in brainstorming. This approach is based on our recognition that, in many respects, patients are the experts; our patients are our teachers. Patients teach us clinicians, and they learn from each other. As we clinicians learn from patients, we become better-informed teachers. Of course, we clinicians also bring professional expertise to this endeavor, such that we think of these groups as an opportunity to pool our collective expertise and wisdom, as well as to continue developing and refining our understanding and knowledge.

For decades at The Menninger Clinic, we have had a strong interest in means by which we might foster a therapeutic alliance in treatment. The therapeutic alliance between patients and treaters requires a degree of trust and a sense of acceptance, but it also entails collaboration, which we construe as the patient’s making active use of treatment as a resource for constructive change. Collaboration is a two-way street in which patients and clinicians are working toward shared goals. We have aspired to develop a psychoeducational program that fosters mentalizing in the context of collaboration. And it is this kind of thinking that led us to make patients actual rather than virtual members of the multidisciplinary treatment team.

Group therapy—not all the same

Psychoeducational Group Psychotherapy is one of three types of group therapies offered at The Menninger Clinic, the other two being Process Group Therapy and Rehabilitative Group Therapy.

Process Group Therapy can be structured and supportive in nature or unstructured and more expressive. In Process Group Therapy, group members often begin to relate to each other and the group therapists in ways that replicate their past and present relationships with others in their everyday life. Process groups provide patients with an opportunity to identify destructive patterns of relating and to gain insight into those patterns and remedy them. Process groups also provide opportunities to identify healthy patterns of relating so they can be reinforced and strengthened.

Rehabilitative Group Therapy focuses on identifying the individual participant’s strengths and weaknesses in every day life functioning, including work, school, social, family and leisure settings. Specific techniques are then used to tap into patients’ strengths so as to habilitate or rehabilitate areas of weakness so as to promote community reintegration and tenure.

All three types of groups have additional therapeutic value.

• Group treatment decreases patients’ experience of being stigmatized, alone, and not understood and increases their appreciation of the value in each person’s uniqueness.
• Process and rehabilitative groups tend to be program specific, whereas psychoeducational groups are open to patients from various programs.

Members learn to:

• Give and to receive feedback in ways that are clear and helpful,
• Negotiate conflict and differences of opinion and
• See themselves through others’ eyes in ways that reduce blind spots in their self-perception and help them take increased pride and confidence in their positive attributes.

It is helpful to have some program-specific groups; each treatment program has a unique vision and mission, and each program needs the opportunity to build a coherent and health-promoting community. Having psychoeducational groups that are open to referral across programs expands the opportunity for varied points of view to be brought to bear on patients’ recovery, for patients across programs to benefit from the specific expertise of staff members and for patients to come to truly embrace the paradox that we are all more alike than different at the same time that we are each unique.

Consistent with our efforts to forge the strongest alliance possible with our patients, the core team—which includes the patient—makes decisions about what hospital-wide psychoeducational groups are appropriate for the patient. In this way, each patient’s treatment becomes individualized.

Examples of Psychoeducational Groups at Menninger
Coping with Trauma. Trauma education groups are conducted in the Hope Program, the Compass Program and the Professionals in Crisis Program. These educational groups are tailored to the typical lengths of stay in the programs, with the Hope and Compass curriculum being somewhat more extended (following psychologist Jon Allen’s book, Coping with Trauma) and the Professionals in Crisis curriculum being somewhat more condensed (following psychologist Lisa Lewis and colleagues’ book, Restoring Hope and Trust). These groups cover the nature and varieties of trauma; the impact of trauma on the self and relationships; the biological basis of posttraumatic stress disorder; the potential range of psychiatric disorders associated with trauma and current approaches to the treatment of trauma.

Coping With the Catch 22s of Depression. This educational group offered in the Professionals in Crisis Program helps patients recognize the challenges in recovering from depression, construed as the catch 22s, the gist of which is that all one must do to recover (e.g., sleep well, engage in pleasurable activities, think realistically, engage in supportive relationships and have hope) is made difficult by all the symptoms of depression. Based on Dr. Jon Allen's forthcoming book, Coping with Depression, the group covers a range of topics, including depression as an illness; the stress-pileup model of depression; developmental factors contributing to depression; interpersonal and intrapsychic conflicts contributing to depression and treatment approaches to depression ranging from behavioral to cognitive and interpersonal. The group includes discussion of the cardinal importance of hope.

Anxiety. This educational group is offered on the Professionals in Crisis Program. The group helps patients better recognize their anxiety symptoms by teaching about the different anxiety disorders, including generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder and obsessive-compulsive disorder. The group aims to help patients recognize the difference between healthy and problematic levels of anxiety, as well as between adaptive and non-adaptive responses to anxiety. The group helps patients employ cognitive-behavioral techniques and general relaxation strategies to assist them in managing their anxiety.

Roles and Relationships. This group, conducted on the Professionals in Crisis and Compass programs, was developed from research in the Menninger Child and Family Program that systematically assessed quality of functioning in relationships in adulthood. Based on the premise that secure attachment relationships play a paramount role in recovering from psychiatric disorders and in wellbeing after recovery, the group provides an opportunity to discuss several types of relationships:

• Friendships
• Romantic relationships
• Family relationships
• Work relationships
• Informal social contacts
• Relationships with therapists
• Relationships with peers in the therapeutic community
• Relationships with addictive substances and activities
• Relationships with self

In addition, the groups discuss relationships with addictive substances and activities, as well as the nature of one’s relationship with oneself. For each type of relationship, the group discusses the distinctive features and potential benefits, as well as problems patients are experiencing and solutions to those problems.

Mentalizing. Research in the Menninger Child and Family Program is highlighting the role mentalizing—interpreting the actions of oneself and others as based on mental states—in resilience to stress and adversity. The concept of mentalizing plays a significant role in Menninger staff members’ thinking about treatment and, with the intention of fostering active collaboration, patients are being educated about the nature and importance of mentalizing. Groups are conducted in the Professionals in Crisis and Compass programs. These groups discuss the concept of mentalizing; developmental factors that promote mentalizing, including secure attachment and optimal levels of emotional arousal; how problems in mentalizing intertwine with various psychiatric disorders, including substance abuse, depression, anxiety, trauma-related disorders and personality disorders; and how the range of inpatient treatment interventions promote mentalizing.

Dialectical Behavior Therapy. Dialectical Behavior Therapy (DBT) is a comprehensive treatment approach to borderline personality disorder and its frequently comorbid conditions such as eating disorders, substance abuse disorders and posttraumatic stress disorder. DBT is an empirically supported treatment approach for this group of patients. It was developed by Marsha Linehan, PhD, at the University of Washington and is traditionally an intensive outpatient treatment. Dr. Linehan and her colleagues have trained several Menninger staff members in DBT. There are three DBT Skills Training Groups open to patients throughout The Menninger Clinic. In addition to being part of the Hope Program, the Adolescent Treatment Program and Obsessive-Compulsive Disorders Treatment Program conduct DBT groups unique to the needs of patients in these specialty programs.

We have modified DBT Skills Training Group to be consistent with our length of stay. DBT Skills Training Groups at Menninger are held twice weekly and teach, model and role play skills from each of the DBT Skills Training Modules.

• Mindfulness skills improve awareness, increase the capacity to derive pleasure in the moment, reduce emotional distress associated with spending more time than is helpful in the past and the present and increase capacity to control our mind rather than allowing our mind to control us.
• Interpersonal effectiveness skills help us to communicate our wants and needs effectively, nurture healthy relationships and set boundaries and limits in ways that preserve self-respect.
• Emotion regulation skills are aimed at reducing vulnerability to negative emotions, modulate expression of negative emotions and increase capacity to experience joy and pleasure.
• Distress tolerance skills help us to learn to tolerate unavoidable pain in life as gracefully as possible without resorting to actions that will make a bad situation worse.

¹Frager, D., Coyne, L., Lyle, J., Coulter, P. L., Graham, P., Sargent, J., & Allen, J. G. (1999). Which treatments help? The patient's perspective. Bulletin of the Menninger Clinic, 63, 388-400.

Publications on Menninger Psychoeducational Groups
Note: A number of the articles below are available in the Library. Books mentioned are available through booksellers and bookstores.

Allen, J. G. (2002). Coping with the catch 22s of depression: A guide for educating patients. Bulletin of the Menninger Clinic, 66, 103-144.

Allen, J. G. (2005). Coping with trauma: Hope through understanding (2nd Edition). Washington, DC: American Psychiatric Publishing.

Allen, J. G., Bleiberg, E., & Haslam-Hopwood, G. T. G. (2003). Mentalizing as a compass for treatment (White Paper). Houston, TX: The Menninger Clinic.

Allen, J. G., Glodich, A., & Kelly, K. A. (2001). Psychoeducational Approaches. In J. G. Allen, Traumatic relationships and serious mental disorders. Chichester, UK: Wiley, pp. 347-372.

Allen, J. G., Kelly, K. A., & Glodich, A. (1997). A psychoeducational program for patients with trauma-related disorders. Bulletin of the Menninger Clinic, 61, 222-239.

Allen, J. G., Munich, R. L., & Rogan, A. (2004). Becoming the agent of your illness (White Paper). Houston, TX: The Menninger Clinic.

Glodich, A., Allen, J. G., & Arnold, L. (2002). Protocol for a trauma-based psychoeducational group intervention to decrease risk-taking, reenactment, and further violence exposure: Application to the public high school setting. Journal of Child and Adolescent Group Psychotherapy, 11, 87-107.

Glodich, A., Allen, J. G., Fultz, J., Thompson, G., Arnold-Whitney, L., Varvil, C., & Moody, C. (in press). School-based psychoeducational groups on trauma designed to decrease reenactment. In A. Lightburn & P. Sessions (Eds.), Community-based clinical practice. New York: Oxford University Press.

Lewis, L., Kelly, K. A., & Allen, J. G. (2004). Restoring hope and trust: An illustrated guide to mastering trauma. Baltimore, MD: Sidran Press.

Stein, H., Allen, J. G., & Hill, J. (2003). Roles and relationships: A psychoeducational approach to reviewing strengths and difficulties in adulthood functioning. Bulletin of the Menninger Clinic, 67, 281-313.

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