The implications of a Psychoeducation group on the everyday lives of individuals with Bipolar Affective Disorder

Abstracts

Há evidências crescentes de que o curso Transtorno Afetivo Bipolar (TAB) pode ser modificado por abordagens psicoterápicas, tais como a Psicoeducação. Assim, o objetivo deste trabalho foi identificar as implicações do grupo de Psicoeducação no cotidiano dos portadores. Para tanto, optou-se pelo estudo qualitativo, do tipo Estudo de Caso. Foram incluídos doze portadores de TAB que tiveram pelo menos seis participações no Grupo de Psicoeducação desenvolvido na Faculdade de Medicina de São José do Rio Preto (FAMERP). Foram realizadas entrevistas semi-estruturadas, gravadas, transcritas e trabalhadas por meio da Análise Temática. Este estudo demonstrou que tal experiência grupal favoreceu a aquisição de conhecimento; a conscientização da doença e adesão ao tratamento; a realização de mudanças positivas na vida; a possibilidade de ajudar outros portadores a se beneficiarem do aprendizado construído no grupo; a descoberta de outras realidades e estratégias de enfrentamento, obtidas por meio da troca de experiências entre os participantes.

Transtorno bipolar; Terapêutica; Enfermagem psiquiátrica; Saúde mental; Psicoterapia de grupo

ORIGINAL ARTICLE

The implications of a Psychoeducation group on the everyday lives of individuals with Bipolar Affective Disorder

Implicancias de un grupo de Psicoeducación en el cotidiano de afectados de Transtorno Afectivo Bipolar

Sarita Lopes Menezes^I; Maria Conceição Bernardo de Mello e Souza^II

^IRN. Specialist in Psychiatric Nursing and Health. M.Sc. in Psychiatric Nursing, Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing. São José do Rio Preto, SP, Brazil. [e-mail]

^IIRN. Ph.D. Faculty, Psychiatric Nursing and Human Science Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

ABSTRACT

There is growing evidence that the course of Bipolar Affective Disorder (BAD) can be altered by psychotherapeutic approaches, such as Psychoeducation. Therefore, this study was performed with the objective of identifying the implications of a Psychoeducation group on the everyday lives of individuals with BAD. To do this, the authors chose to perform a qualitative case study. Participants included twelve individuals with BAD who had attended at least six meetings of the Psychoeducation Group held at the São José do Rio Preto Faculty of Medicine (FAMERP). Semi-structured interviews were performed, which were recorded and then transcribed and subjected to Thematic Analysis. The present study showed that the referred group experience promoted the individuals' knowledge acquisition; their awareness regarding the disease and adherence to treatment; their making positive changes in life; the possibility of helping other patients to benefit from the knowledge learned in the group; and their awareness regarding other realities and coping strategies, obtained by exchanging experiences with other participants.

Descriptors: Bipolar disorder; Therapeutics; Psychiatric nursing; Mental health; Psychotherapy, group

RESUMEN

Existen crecientes evidencias de que el curso del Transtorno Afectivo Bipolar (TAB) puede modificarse por abordajes psicoterápicas, como la Psicoeducación. Este trabajo objetivó identificar las implicaciones del grupo de Psicoeducación en el cotidiano de afectados. Para ello, se optó por estudio cualitativo, tipo Estudio de Caso. Fueron incluidos doce afectados de TAB que tuvieron cuanto menos seis participaciones en el Grupo de Psicoeducación desarrollado en la Facultad de Medicina de São José do Rio Preto (FAMERP). Fueron realizadas entrevistas semiestructuradas, grabadas, transcriptas y trabajadas mediante Análisis Temático. Este estudio demostró que tal experiencia grupal favoreció la adquisición de conocimiento; la concientización de la enfermedad y adhesión al tratamiento; la realización de cambios positivos en la vida; la posibilidad de ayudar a otros afectados a beneficiarse del aprendizaje construido en el grupo; al descubrimiento de otras realidades y estrategias de tratamiento, obtenidas mediante intercambio de experiencias entre participantes.

Descriptores: Trastorno bipolar; Terapéutica; Enfermería psiquiátrica; Salud mental; Psicoterapia de grupo

INTRODUCTION

Bipolar Affective Disorder (BAD) is a chronic and complex mental illness with high morbidity and mortality rates, characterized by mania or hypomania episodes, alternating with periods of depression and/or euthymia⁽¹⁾. It is estimated that bipolarity can affect about 1% of the general population. Studies on the bipolar spectrum indicate, however, a %% prevalence rate. In general, the first symptoms appear in adolescence, more specifically between 18 and 22 years of age⁽¹⁾.

Depression is accompanied by mood swings, psychomotor, cognitive and vegetative function changes. Other symptoms also characterize the clinical situation, such as depressive mood, inability to feel joy or pleasure, psychomotor slowing or agitation, concentration difficulties and negative thoughts⁽²⁾.

In the mania phase, the mood is expansive or euphoric, but can also be irritable and uninhibited. In addition, decreased sleep needs, restlessness, psychomotor agitation, increased energy and libido also occur. Besides, in this phase, ideas of greatness, prolixity, pressure to talk, harm from criticism and increased impulsiveness are common in this phase. Hence, social conduct becomes inadequate, patients can become indiscrete, invasive, and may increase the consumption of alcohol and/or other drugs, increase their financial spending and involvement in potentially harmful activities, such as high-speed driving, sexual promiscuousness and debts⁽²⁾.

BAD is associated with increased mortality risks, as approximately 25% of patients try to commit suicide at some moment in their life^(3-4), 11% of whom are successful⁽³⁾. This rate is even higher with regard to untreated patients, reaching 15%⁽⁴⁾.

In view of all of these alterations, BAD strongly affects patients' occupational functioning, who experience more work-related problems than the general population⁽²⁾.

BAD treatment includes pharmacological and non-pharmacological strategies. The former comprise mood stabilizers like lithium, anticonvulsants and antipsychotics. These aim to control the acute phase, prevent new episodes and play a fundamental role in synaptic plasticity repair, compensating for a range of structural and functional alterations in certain brain regions the relapses provoke⁽⁵⁾.

Although strong biological indicators characterize BAD and pharmacological treatment is unsurpassable, psychosocial care is needed as, in strictly biological treatment, non-adherence and relapse rates are high. Hence, it is fundamental to associate complementary treatments that aim for the clinical application of the bio-psycho-social model and the inclusion and valuation of patients and relatives' participation⁽⁶⁾. What is more, there is increasing evidence that the course of BAD can be modified through psychotherapeutic approaches. These are aimed at enhancing treatment adherence, reducing residual symptoms, identifying syndromic prodromes and, consequently, preventing relapses, decreasing hospitalization rates and periods and improving patients and their relatives' quality of life. Besides, they enhance these patients' increased social and occupational functioning and abilities to manage stressful situations in their lives⁽⁷⁾.

Non-pharmacological approaches include Psychoeducation, developed since the 1970's as a treatment additional to drugs, aimed at maintaining patients in the community⁽⁶⁾. In general, Psychoeducation is considered one of the main strategies to modify negative aspects BAD patients experience and involves informing patients and relatives about the nature and treatment of the disease, providing theoretical and practical teaching with a view to enhancing their understanding and coping with the disease. Also, this strategy aims to help patients to improve their insight about the disease, cope with stigmatization, improve treatment adherence, teach about early prodromic signs, promote healthy habits and regular lifestyle and avoid substance abuse^(7-8).

Thus, this study aims to identify the implication of a Psychoeducational group in BAD patients' daily life based on their perspective.

METHOD

This research only started after the Institutional Review Board at Faculdade de Medicina de São José do Rio Preto (FAMERP) gave a favorable opinion, with a view to guaranteeing ethical aspects (Protocol No 7049/2007).

A qualitative case study was accomplished, including 12 BAD patients who participated in six or more meetings of the Psychoeducational group. The saturation sampling method was used to determine the number of study subjects. Thus, new subjects were included until verifying that many repetitions occurred, that interview contents were very similar and that, hence, further interviews would offer hardly significant additions, without qualitative modifications for further analysis of the results.

The Psychoeducational group in this study takes place at São José do Rio Preto Medical School (FAMERP). It has been offered since September 2003. Initially (until November 2005), it was part of the Bipolar Mood Disorder Relapse Prevention Program, in partnership with the Study Group on Affective Diseases (GRUDA) at the Instituto de Psiquiatria do Hospital das Clínicas de São Paulo. It is an open group that meets monthly. On average, 30 people participate (including family members and patients), who are invited through newspaper advertisements, posters distributed at Mental Health Services in the city, and also personally by professionals who participate in the group or are our collaborators.

For each lecture, a one-hour lecture by a professional is programmed: nurse, psychiatrist, psychologist, nutritionist, physical educator, lawyer, among others, according to the theme set for that day and the professionals' knowledge area. As for the themes addressed during the lectures, participants themselves suggest them when answering a meeting assessment questionnaire, which is applied each year. In general, themes include the characteristics of different disease phases; causal and triggering factors; pharmacological and non-pharmacological treatment; pregnancy and genetic counseling; early detection of maniac and depressive episodes; alcohol and other drugs; psychological, social and economic losses; stress management techniques; how to deal with a relative suffering from BAD; strategies to live with daily lifestyle changes and to improve quality of life (food and physical exercise); rights of patient and relative; among others. After the lecture, a relative or patient presents a voluntary testimony, aimed at exchanging experiences and stimuli. Besides the testimony, the participants express their thoughts and/or doubts about the theme, which the professionals clarify. The meetings end with a snack to enhance approximation between relatives/patients and professionals, thus contributing to strengthen mutual bonds.

To collect the data, semistructured interviews were held, recorded and later transcribed by the researcher, leaving room for contents beyond the questions. After data collection, the interviews were subject to Thematic Analysis. The guiding questions of the interview were: Tell me what your daily reality is like and What has it been like for you to participate in the Psychoeducation group?

RESULTS

Subject Characteristics

Research participants were 12 female subjects, between 35 and 73 years old, five of whom where married, four divorced, two single and one widowed. Regarding education, all participants could read and write, but only three finished secondary education and three reached higher education. At the time of research, six were employed, four were housewives and one was retired due to the mental illness. Attendance to the Psychoeducation group ranged from six to 17 times. Half of the women participated ten times or more.

Among the 12 interviewed women, 11 had already done psychotherapy at some time in their lives, only four of whom were still doing this treatment type. As for psychiatric hospitalizations, six had already been hospitalized in a psychiatric institution, with six hospitalizations as the higher incidence rate. All hospitalizations preceded participation in the Psychoeducation group.

Implications of the Psychoeducational group in Bipolar Affective Disorder patients' daily life

The implications of the Psychoeducational group in the daily life of Bipolar Affective Disorder patients will be analyzed through four thematic subcategories: Knowing the Bipolar Affective Disorder; Enhancing awareness of the disease and treatment adherence; Promoting changes in life and The patient as a source of help.

Knowing the Bipolar Affective Disorder

When mentioning what it was like to participate in the Psychoeducational group, the importance the participants attribute to gaining knowledge about the BAD is surprising. As observed in the testimonies, some patients were already suffering the consequences of the disease for many years but, nevertheless, did not clearly understand the meaning of that all. Some even mentioned that, although they had been under medical follow-up for quite some time, they did not get this kind of clarifications during the consultations.

In addition, they see the group as a safe and reliable place, which stimulates them to ask questions and present experiences about the illness, without fear of being victims of prejudice between they identify themselves as mental illness patients, a prejudice that is still very common in the society we live in. In that sense, they also indicate that getting this information from specialized professionals on the theme makes them feel more confident, which is not necessarily the case when one seeks information from other sources, susceptible to distortions, trends and prejudices.

Thus, they reported that, through the lectures and discussions in the Psychoeducational group, they started to know themselves better, to be able to deal with BAD manifestations better, as well as to avoid unnecessary hospitalizations...

(...) by coming here, right, participating in the program, that's how I really understood what bipolar disorder is and that the symptoms I felt before were all related to the bipolar disorder (...) (Antônia).

(...) I had never heard of bipolar disorder (...) I trusted a lot in what the professionals told me, because it's very complicated for you to take, read something in a magazine and another person comes to talk and... I've often seen wrong things. So, there I felt safe (...) it was a safe haven for me... It was a blessing, you see?! It was a blessing! (Fátima).

(...) you know when you want to fall, you know when you're about to, almost...losing it. I've learned a lot here in the course, because you can't know just through the medical consultations. You learn a lot here, I think it's really worth it (...) for you to know yourself (...) because these people (...) who don't know much, anything (...) they go to the Psychiatric Hospital! (...) (Laura).

(...) all of this through the knowledge, the help from the Psychoeducational group, you see?! The doctor doesn't explain that to you, he gives you medication and that's it (...) (Jurema).

Enhancing awareness and treatment adherence

The testimonies revealed the extent to which knowledge about BAD can enhance commitment to treatment and, thus, the extent to which Psychoeducation plays a fundamental role in this regard. By understanding the dynamics of the disease, its cyclical and chronic nature, as well as the harm the constant relapses cause, the patients gain awareness that they suffer from a mental disorder and that they need to perform treatment adequately.

At the same time, we observe that they realize they can be active participants in this process and that this treatment adherence will grant them a better quality of life. In that sense, they mention the possibility of returning to their personal and professional life as a benefit of this awareness about the disease and treatment adherence, despite the disorder, managing their lives instead of living at the mercy of the disease's ups and downs.

It is observed in the testimonies that Psychoeducation is not the sole and miraculous solution to the complexity of the problems involved in BAD. Nevertheless, it significantly influences the awareness process about the disease and, consequently, treatment adherence. This influence is evident in one subject's testimony, mentioning that her participation in the group represented the final drop to fill her bucket, that is, that her life experiences, the mania and depression episodes, as well as the many other resources she had already sought, including Psychoeducation, offered her great learning and, in her words, filled her bucket, attending to her need for answers. Thus, by promoting answers not found until then, the Psychoeducational group collaborated towards her awareness of the disease and treatment adherence:

(...) I was almost ready for this awareness already and I'd say the Psychoeducational was the final drop for me to assume this whole posture I have today, everything I think, everything I think about my disease, my entire trajectory (...)(Dalva).

(...) the Psychoeducational, it makes you aware that this disorder is a disease and that it has to be treated, it has to be taken seriously (...) it prepares you, you, to live with you, to live with your disease (...) because that's not somebody else's problem, it's yours and you're the one who has to solve it (...) (Jurema).

(...) I think that the group, the psychoeducational (...) gives you this awareness, right, that you are capable of having a healthy life, work, live normally! (...) So you're the one who has to accept it, the disease is yours (...) (Jurema).

(...) I didn't accept that I had to take medication for the rest of my life, right. And this here helped me a lot. This here helped me a lot! (...) here, right, it's the key to it all, for us to accept, that we have to take care of ourselves, we have to take the medication correctly, we have to go to the psychiatrist, we have to go to the psychologist and live with it (...) (Antônia).

Promoting changes in life

The previous subcategories discussed the role of Psychoeducation in knowledge acquisition, in the patient's gaining awareness about the disease and treatment adherence. How this can affect these patients' lives in what we analyze in this subcategory.

As observed in the testimonies, participating in the Psychoeducational group promoted significant changes in patients' lives. In this respect, they indicated that they started to lead a normal life, that is, they returned to their daily activities, like secular work and household responsibilities, activities that were intensely compromised in some patients' lives. They also mentioned the possibility of needing fewer hospitalizations, as they learned to deal better with the disease and its consequences.

Besides, they declared that participating in the group enhanced their self-esteem, contributed for them to feel happier and helped them to live with their new life situation as well as possible, despite the BAD.

(...) And thanks to this here I had, like, right, I have, I have a normal life (...) I go to work, I come back, I clean my house, I do the laundry, I make food (...) (Antônia).

(...) out of a hundred that go there (Psychoeducational group), if you help one, no matter whom, that's one less at the psychiatric hospital, that's one less suffering on Planet Earth! You can be sure that it's not just one (...) like me, I think there were so many people who changed their behavior, changed life (...) who got a great change in life from the psychoeducational! (...) (Dalva).

(...) the psychoeducational is very important (...) sometimes one word you hear, and which he uses changes a whole situation (...) (Jurema).

(...) I perceive that I am able to improve my self-esteem (...) I am more balanced, I liked it a lot to participate in the Psychoeducational, it was really worth it. I saw that I wasn't that bad, like, as a person and that I could improve (...) (Madalena).

(...) with regard to the group, I remember that, last time (...) there was a psychologist, he said that the best thing in the world is still work, right, so that deeply touched me, right, because I was lying down until 10 a.m. Then I had lunch, sometimes I made lunch, and went to lie down again, I felt really lazy, but like, really lazy, it wasn't depression (...) today I'm a happier person, right, and the group, like, it added positive parts for me (...) (Madalena).

The patient as a source of help

The testimonies also reveal that the importance of the Psychoeducational group is not only limited to professional interventions, when they provide theoretical and practical knowledge about the BAD, but also that most of the benefits this type of approach offers can be attributed to the exchanges that exist among the participants themselves. The reports reveal the extent to which they value the knowledge constructed through other patients' experiences.

Initially, the subjects describe their satisfaction to meet people with problems similar to their own, which on the one hand offers consolation, as they realize they are not the only one to suffer from this disease. On the other hand, the experience a feeling of relief, due to finding experiences in these people that are considered I than their own.

According to the interviewees, we also understand that both the patient or relative's formal testimony during each group meeting and the informal talks before or after the meetings intensely benefit patients. They report having changes some inadequate behavior or even having sought a new strategy to deal with the consequences of the BAD in their life based on what they heard about the experiences of other patients present during the meetings.

Besides, patients as a source of help involves the Psychoeducational group environment, of mutually cooperating participants. We detected in the reports that, while the psychoeducational intervention benefits the patients, they feel motivated to help other people beyond the group context, whom they identify with in terms of suffering, life history and the nature of the disease. This is reflected in the clarifications the group provides to these people about the BAD, the behavioral changes, the need to adhere to treatment and, more indirectly, because patients invite others to participate in the Psychoeducational group, underlining that, like him, they will find help there to deal with the difficulties involved in the BAD.

Thus, we understood that, for these subjects, the Psychoeducational group also grants the opportunity to help other people, as well as to be helped by other patients.

(...) I saw that, talking to the people there (Psychoeducational Group), I was an instrument of help too, of being able to help, encourage (...) (Dalva).

(...) the son has, has bipolar disorder and he lost everything he had and lost everything the parents had (...) this woman was really crying (...) I took her hand, like, and I talked to her about the Psychoeducational, that it helps, right, for her to live with it better (...) you want to get the person and, like, you know, carry her on your lap, because you know what the disease is, you know what the person is feeling (...) (Jurema).

(...) the people we met (in the Psychoeducation Group), right, each testimony was worth it to improve something in life, in our daily reality (...) (Madalena).

(...) each person with a type of problem, with a type of exit, with a different escape. So, you go, listen to one here, listen to another there and then I said "Hey, wait!' 'I need to find an escape, a way!' Then I started to listen to music, read a book (...) I didn't have those strategies yet, no (...) it was by going to the group that I started to stop to think 'No, I'm going to do this, I'm going to do that' (...) (Emília).

(...) I saw that 'Hell, I'm not alone!' There are so many people with the same problem as I! (...) being able to talk to these people, it's a unique possibility, you know!?(...). Hell! The other day, I heard a woman say that she bought 10 televisions. I said 'That's good!' (laughs) 'It's not just me!' (...) there (in the Psychoeducational Group) I felt more normal (Fátima).

DISCUSSION

Regarding the knowledge provided in the Psychoeducational group, a literature review about the efficacy of Psychoeducation in BAD mentions that this intervention mode enhances the course of the disease because, among other things, it furthers participants' increased knowledge about the disease⁽⁹⁾.

In addition, a two-year prospective study that compared two groups of 25 type I bipolar patients going through remission, both under pharmacological treatment; however, Psychoeducation was applied in only one group. One of the findings in this research was that Psychoeducation helps patients to detect the prodromic signs of the BAD early, which definitely contributes to an earlier intervention and, consequently, to improve these people's lives⁽¹⁰⁾.

When assessing the efficacy of Psychoeducation and other BAD-related strategies, a study mentions that Psychoeducation helps the patient to focus on the BAD in a more singular way, that is, patients start to understand their disease and not simply the disease. This involves self-knowledge, understanding the association among the symptoms, their personality traits and temperament and the medication side effects. Besides, it is added that Psychoeducation helps them to acknowledge subtle behavioral changes that can predict a new episode. Also, when saying that patients start to see their disease, this refers to the patient's accountability, i.e. that Psychoeducation helps them to participate actively in treatment and feel responsible for managing the disease, which is fundamental for treatment success⁽¹¹⁾.

Thus, Psychoeducation should contribute for BAD patients to understand and give meaning to the experience they live, applying this understanding in their daily life and demonstrating greater valuation of their life, which attends to the patient's need for support and information as, in general, this demand is not satisfactorily attended to during medical consultations⁽⁶⁾.

In an analysis of this treatment adherence problem among bipolar Americans, a research identified the following risk factors for non-adherence: alcohol dependence, being young, the grandeur of affective morbidity, various types of effects, comorbidity with Obsessive-Compulsive Disorder and recurrence of mania/hypomania. Besides, a potential relation between treatment complexity and adherence was found⁽¹²⁾.

It was also verified that BAD patients experience ambivalence with regard to medication treatment, which they associate with suffering, disease, control, need, obligation, habit and guilt or, then, with support, blessing and savior⁽¹³⁾.

Thus, treatment adherence in BAD is a multidimensional problem that includes the patient's own characteristics, as well as other related factors and, therefore, the therapeutic approaches that incorporate these aspects offer better results, optimizing treatment intensity and improving treatment adherence attitudes and behaviors⁽¹⁴⁾.

In that sense, individuals participating in Psychoeducational groups can be capable of understanding the BAD better, which furthers acceptance of the disorder and treatment adherence⁽⁸⁾.

This is confirmed by a research that involved 120 BAD patients in remission, who were receiving standard psychopharmacological treatment without psychotherapeutic accompaniment at the time of study. Patients were divided in two groups, one of which served as control, with unstructured sessions. Subjects in the other group participated in 21 weekly Psychoeducation sessions that focused on the identification of prodromic symptoms, treatment adherence and the need to maintain a regular lifestyle. After two years of follow-up, this study concluded that the Psychoeducational group contributed to a significant reduction in relapses, hospitalizations and hospitalization days⁽¹⁰⁾.

Also regarding the role of Psychoeducation in this respect, a study analyzed relapse episodes in 58 BAD patients in remission, dividing them in two groups. Both groups received medication group, but only one was submitted to 12 weekly 90-minute Psychoeducation sessions (27 patients). The study ended with a 45-patient sample, 29 of whom remained euthymic up to the 60^th week, 17 of whom belonged to the Psychoeducation group; 16 suffered a relapse, only three of whom from the Psychoeducation group. Besides, it took longer for relapse to happen among Psychoeducation patients (11 weeks longer than the other group). Thus, it was confirmed that Psychoeducation reduces relapses in BAD and enhances treatment adherence. Therefore, its application together with medication treatment is encouraged⁽¹⁵⁾.

Another study that assessed the efficacy of a Psychoeducational group compared two groups of euthymic BAD patients for five years, totaling a sample of 120 patients. One of the groups was submitted to Psychoeducation and the other to a non-structured intervention. That study concluded that six months of Psychoeducation exert more lasting prophylactic effects on BAD, as this reduces the number of any kind of relapses, increases time between relapses, decreases the number of hospitalization and how long patients remain sick during relapses. Besides, the adherence rate between the two groups was verified before and at the end of the study, with a low rate in both group at the start and an even lower rate at the end of the study, also in bad groups⁽¹⁶⁾.

Although some physicians highlight adherence as the main improvement after Psychoeducation use, however, it also plays a fundamental role in changing aspects in patients' affective-emotional life, which is the most important for family members, as they value improvements in social adjustment more than adherence itself⁽⁶⁾.

Thus, the benefits of Psychoeducation go beyond adherence, decreased relapse and hospitalization rates. They also include patients' better quality of life, as it enhances their self-esteem and wellbeing, decreases stigma and guilt and reduces comorbidities and lifestyle changes⁽¹⁷⁾.

In this respect, a research proves that complementary psychotherapy significantly improves fundamental and symptomatic outcomes in BAD, for periods of more than two years. In that study, the author compared 18 psychotherapeutic approach experiences, considering recovery time, recurrence, duration of episodes, symptom severity and psychosocial functioning. Among different interventions, individual Psychoeducation and systemized care programs were more effective during maniac than during depressive episodes and Family and Cognitive-Behavioral Therapies stood out in the treatment of depressive symptoms⁽¹⁸⁾.

As for the opportunity the Psychoeducation group offers for experience exchange, BAD patients highly value this possibility of sharing experiences, knowledge and feelings, which grants them a feeling of relief and decreased guilt. This experience exchange also furthers other aspects: patients' increased self-esteem, as they feel more values because they can benefit other participants; the development of social skills and the non-reproduction of behaviors that entail negative consequences⁽⁸⁾.

In that sense, it is fundamental to stimulate interaction among all participants in the Psychoeducation group, so that they have the opportunity to express their feelings, thoughts and experiences involved, which will help them to perceive that they are not alone, that other people also have similar problems⁽¹⁷⁾.

Although the opportunity to meet new people and the possibility to exchange experiences are generally mentioned as positive aspects of the Psychoeducation group, other patients consider them negative, alleging that they make the meetings tiresome, according to them, as well as unnecessary⁽⁸⁾.

In this sense, some patients do not benefit that much from group Psychoeducation. Some reports indicate increased anxiety, fear, pondering and obsessive mood state checking after submitting to this treatment approach, which reveals that adverse effects are possible⁽¹⁸⁾.

CONCLUSION

The analysis of what the subjects described about what it was like for them to participate in the Psychoeducation group provided us with some answers to the questions asked: What is the actual contribution of Psychoeducation in these BAD patients' lives? How does Psychoeducation enhance the prevention of relapses? What changes in these subjects' life as they start to participate in the Psychoeducation group?

Thus, this analysis allowed us to understand the implications of the Psychoeducation group in the daily reality of BAD patients. In that sense, the results demonstrate that this group experience particularly enhanced the following aspects: knowledge acquisition about BAD; awareness-raising about the disease and treatment adherence; accomplishment of positive changes in life; possibility of helping other patients to benefit from the learning constructed in the group and the discovery of other realities and coping strategies, obtained through experience exchange among the participants.

As for the opportunity the group offered them to obtain further knowledge about the BAD, we perceived that some of them had been suffering the consequences of the disease for decades, and had even undergone some treatment form. It was in the group, however, that they were able to most fully understand the meaning of all that and learn to deal with these changes most adequately. This reinforces the extent to which mental health professionals need to be prepared to play their role as educators.

It is known that, nowadays, communication means facilitate information access, including internet, television, books, magazines and newspapers. In a way, this enhances patients' knowledge acquisition. As they highlighted in the interviews, however, these sources are not necessarily reliable, which may cause distortions, reflect prejudices and trends in the lay population. Therefore, they see the Psychoeducational group as a safe and reliable place to obtain information and clarifications. Hence, for patients to get to know the BAD better, much will depend on how we prepare ourselves as professionals to exert this educative function.

What awareness about the disease and treatment adherence is concerned, we concluded that Psychoeducation truly plays a fundamental role in this respect. By understanding the dynamics of the disease, its cyclical and chronic nature and the harm constant relapses cause, they gain awareness that they suffer from a mental disorder and that they need to get adequate treatment. They also indicated that the Psychoeducation group helped them in the accountability process and that they started to see themselves as active participants in treatment.

We also concluded that the group furthered the return to some activities that used to be quite compromised, such as housework and work. Besides, they mentioned other positive changes, such as increased self-esteem and a happier and more significant life, despite the disorder.

We also verified that part of the benefits of this type of approach derive from the exchanges that exist among the participants themselves. When they perceive themselves in a peer group, they feel comforted and relieved. Besides, they reported that they changes some inadequate behavior or even sought a new strategy to deal with the consequences of BAD in their life after having listened to other group members' experiences. At the same time, patients also see themselves as a source of help for other patients and family members.

It should be highlighted that, although the Psychoeducational group played an extremely important role in these subjects' daily reality, this was not the only form of help they received. They also benefitted from other forms of help, such as psychotherapies, self-help groups, work, religion, physical exercise, good food and support from friends.

Thus, we conclude that no single treatment form exists that can handle the complexity involved in BAD-related problems. Hence, any intervention that ignores or devaluates the different forms of healthcare, in their bio-psycho-socio-cultural aspects, can be deemed to fail, given the meaning patients themselves attribute to these forms.

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Correspondence addressed to:

Publication Dates

• Publication in this collection
  20 Mar 2012
• Date of issue
  Feb 2012

History

• Received
  26 Jan 2010
• Accepted
  20 Aug 2011