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
"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
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>.▪