The principles and practices of psychoeducation with alcohol or other drug use disorders: A review and brief guide

Abstract

Overview.

In the current work, we build upon a small body of literature that delineates cross-cutting factors, or processes, of evidence-based alcohol or other drug (AOD) therapies. Here, we discuss Psychoeducation. We define psychoeducation as a brief process of therapy focused on the communication of varied aspects of disease- and/or treatment-related information.

Method.

The authors conducted a literature review and qualitative content analysis to derive a set of principles and practices of psychoeducation. The review used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO.

Results.

The review identified nine principles and 21 practices. Together, the principles suggest that psychoeducation in evidence-based addictions therapies can be characterized as a collaborative approach to teaching, education, or other provision of information. The term collaborative denotes a shift in emphasis from compliance to a more egalitarian partnership focused on meeting individual health needs. Specific practices included ways to transition to psychoeducation (e.g., provide rationale and promote expectancy), teaching methods in psychoeducation (e.g., use plain language), tailoring content in psychoeducation (e.g., to learning style, to cultural worldview), and methods for facilitating a dialogue about the information (i.e., five question types), for facilitating understanding and retention of the information (e.g., tailor to individual needs, use of varied teaching modalities), and how to end psychoeducation and engage in related goal-setting, where applicable.

Conclusions.

We frame psychoeducation as a collaborative approach to teaching where client engagement, understanding, and utilization of the information provided is the central goal. We offer a novel resource with pragmatic value to trainees, providers, and clinical supervisors who do not consider themselves aligned with a single evidence-based modality but who may benefit from training and proficiency assessment in core, behavioral health counseling competencies.

1. Introduction

The National Institutes of Alcohol Abuse and Alcoholism and Drug Abuse (NIAAA; NIDA, respectively) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have identified several evidence-based therapies for alcohol or other drug use disorders (AOD) with moderate and generally similar effectiveness (e.g., Center for Substance Abuse Treatment [CSAT] 2012, 2017; SAMHSA, 2018; NIAAA, 2014; NIDA, 2018). Despite this progress, a striking one in 10 individuals in need of treatment ever receives it (CSAT, 2019), and for those who do receive treatment, relapse and regression rates continue to hover at 40 to 60% (NIDA, 2018). As a result, future efforts in addiction science must address the availability of quality care. Grounded in the recognition that a truly novel behavioral treatment discovery is unlikely, many researchers have turned their attention to improving the quality of treatments that are already available. This work includes efforts to identify: 1) active ingredients and patient-mechanisms of behavior change (e.g., Huebner & Tonigan, 2007; Mechanisms of Behavior Change Satellite Committee, 2018), 2) methods for implementing evidence-based treatments in frontline settings (e.g., Damschroder & Hagedorn, 2011), 3) methods for optimizing provider training and supervision (e.g., Martino et al., 2008), and 4) a well-overdue shift toward common factors, or processes, of behavior change therapies (e.g., National Institutes of Health, Science of Behavior Change Initiative).

Operationalizing processes that are cross-cutting in addictions therapies is a viable approach to improving frontline care, particularly when the majority of addiction care providers do not subscribe to a single evidence-based modality (SAMHSA, 2018), and because evidence suggests no single modality is uniquely efficacious over another (Imel, Wampold, Miller, & Fleming, 2008). In prior work, we targeted a single, cross-cutting therapeutic process, skills training, and we operationalized this process to facilitate provider training and quality control (Magill, Martino, & Wampold, 2020). Here, we target a second process—psychoeducation. Psychoeducation has a long history in psychiatry and patient medical education. Often, the literature uses the term for a stand-alone intervention with, for example, families of those with major mental illness (Goldman, 1988), but we frame psychoeducation similar to how we framed skills training: as a process of treatment that is widely applicable to both specific-modality and technically eclectic care. We consider this process to be cross-cutting in addictions, but its centrality to intervention will vary from one modality (e.g., a high emphasis in a brief, feedback-driven intervention vs. a low emphasis in a prototypical motivational interview) or provider context (e.g., a high emphasis in a detoxification program vs. a low emphasis in a general practice, psychotherapy setting) to another.

1.1. Objective

In the current work, we review the literature on psychoeducation in addictions, and to a lesser extent, mental health. To provide a comprehensive overview, we additionally consider the literature in patient medical education, health literacy, and adult learning theory, more broadly. The goal is to delineate a set of principles and practices of psychoeducation. While our review results will first delve into a working definition of psychoeducation, we define three other terms here. First, the definition of a principle is a broader understanding or way of being on the part of the provider that must be kept in mind when implementing a specific therapeutic practice. Second, a practice is an action step or specific type of technique that the provider uses when delivering therapeutic content. Third, content refers to the material covered in psychoeducation, which will depend on the goals and orientation of the treatment modality and/or clinical-care context, and is not of major concern to the current review. We focus on how to deliver high-quality psychoeducation, regardless of the content or the treatment delivered. We do not claim that content is unimportant, but that the existing literature addresses it (e.g., government websites, books, articles, or intervention manuals) and, thus, we do not address it here.

2. Materials and methods

2.1. Literature review: A conceptual overview of psychoeducation

The literature review involved a title search in PUBMED (August of 2020), using the following terms “psychoeducation”, “patient education”, “health literacy” AND “review”, “meta-analysis”, “systematic review”. Inclusion criteria were theoretical or empirical review manuscripts on: 1) history, 2) definition, or 3) key practices or other guidelines. This search yielded 986 documents that the first author title, abstract, and full-text screened. While manuscripts in the addictions field were a priority, the study staff examined all health and mental health disciplines given our emphasis on the how, rather than what, of psychoeducation. Further, we drew from our prior selection of purposively sampled manuals and demonstration videos specific to addictions care. We briefly describe this selection process and the content analysis methodology next.

2.2. Qualitative Content Analysis: Identifying the principles and practices of psychoeducation

In the current work, we build upon data collected in our prior study. Specifically, we obtained a representative selection of evidence-based therapy manuals and government-issued practice guidelines. The search process included expert consultation; review of recommended treatments (e.g., NIDA, 2018); and access to available manuals on government websites such as NIAAA, NIDA, and SAMHSA. We also obtained therapy demonstration videos from two providers of video-format educational content on psychotherapy. We selected all available videos focused on treating substance use disorders and addictions (e.g., American Psychological Association [APA]: Specific Treatments for Specific Populations Series; Pychotherapy.net: Brief Therapy for Addiction Series). Finally, we used peer-reviewed articles screened eligible in the literature review phase as additional sources for the qualitative content analysis described here. The result was a sample of 10 therapy manuals, 11 therapy training videos, 27 theoretical overviews/literature reviews, and 4 practice guidelines (see Supplemental Table 1 for full list). The first author collected all data in NVIVO (version 12).

Using an a priori framework for a qualitative content analysis (Erlingsson & Brysiewicz, 2017), the study team reviewed source materials. The framework targeted principles and practices of psychoeducation. We were interested in forms of teaching (i.e., provision of information) that did not correspond with a subsequent, experiential practice component, as the existence of the practice component would denote skills training (Magill, Martino, & Wampold, 2020). Using the noted definitions, we extracted each qualifying principle or practice as a single reference from the selection of sources. The team placed references (i.e., bullet point, sentence, paragraph, or video observation) in a growing list that was then organized into broader categories, or nodes. We based node assignments on shared subject matter; for example, we grouped all excerpts about the “teach back” technique into a single node called Ask questions to check for understanding of information. Principles were rare in the data relative to practices, which were more frequent both within and across sources. As a result, the research team counted each excerpt containing a reference to a given practice to provide a frequency measure of salience in the data. Moreover, nodes could be organized into broader themes about principles of psychoeducation. In other words, the team derived principles both as direct references and as themes arising from recommended practices. Finally, to enhance rigor and credibility, a trained research assistant rated excerpts from a 10% sample of source references. In this case, we reversed the order of operations to achieve a confirmatory goal. The research team provided the research assistant with the operationally defined principle and practice categories (i.e., Tables 1 and 2) and asked them to make an orthogonal code (i.e., select only one designation) for each excerpt. This process is called a “check on clarity of categories” (Thomas, 2006). Results yielded an alpha of .94 for agreement against ratings provided by the first author (see Supplemental Table 2 for source excerpt examples), where values above .80 are considered acceptable (Krippendorff, 2004).

Table 1.

The principles of psychoeducation.

Principle	Description
1) Psychoeducation is empowering	Information is provided to empower clients to become central actors and collaborators in their treatment.
2) Psychoeducation is well-informed	When information is provided, it should be the best available information (e.g., grounded in high quality research).
3) Psychoeducation is understandable	When information is provided, every effort must be made to ensure that information is understood by the client.
4) Psychoeducation is brief	Brevity is important when providing information; not only for engagement, but also for retention.
5) Psychoeducation is interactive	Providing information in a dialogue facilitates client engagement with the material.
6) Psychoeducation is tailored to individual needs	The provider must match teaching to client learning style, cultural worldview, and/or attentional capacity in the moment.
7) Psychoeducation may end with a goal	While not necessary, often information is provided with the intent of setting a goal centered on the use of that information.
8) Psychoeducation uses both facilitation and teaching skills	The aims of information-giving in psychoeducation (e.g., empowerment, understanding, and often a goal) requires both facilitative-counseling and didactic-teaching skills.
9) The psychoeducation provider is a charismatic, client-centered expert	The psychoeducation provider must be an expert, while attending closely to both persuasion and connection.

Table 2.

The practices of psychoeducation.

Practice	Description
Transitioning and structuring
Begin with permission to provide information	Provider asks permission to give information prior to giving information to the client.
Begin with a rationale for the information	Provider begins with a clear rationale for information, which should orient the client to the need for the information and promote expectancies around the value of the information.
Maintain focus on information with structure	Provider uses structure and time-management to ensure that attention to information is thorough.
Teaching
Provide information using plain language	Provider always uses simple language, avoiding acronyms, jargon, or other specialized terminology when giving information to the client.
Provide information using client language	Where possible, the client’s own words, symbols, and phrases should be used to communicate information.
Provide information at a moderate pace	Information should be communicated at a moderate and steady pace; the provider should never rush information.
Provide information in small, meaningful units	Information can be organized into small units to facilitate learning and retention.
Scaffold information with increasing difficulty	Information can be scaffolded such that later information builds on earlier information with increasing difficulty.
Tailoring
Adjust teaching to learning needs	Provider must assess the client’s learning needs and adjust their methods wherever possible.
Adjust teaching to language and culture needs	Provider should adjust to language and cultural needs, including language-appropriate teaching materials and incorporation of cultural meanings and symbols.
Adjust teaching to non-verbal indicators of attention	Provider should attend to indicators of waning attention, non-verbal or otherwise, and adjust their methods if it appears they are losing client engagement with the information.
Facilitating interaction
Ask clients what they already know about the information	When providing information, it is vital to assess what information the client already has on a given topic.
Ask client to ask questions	When providing information, always ask “what questions” the client has about the information.
Ask client questions to check understanding of information	When providing information, always check for understanding with specific strategies such as requesting the information be repeated back or applied in a personal example.
Ask client questions to explore reaction to information	When providing information, questions can be used to explore how the client perceives the information and how they intend to use the information.
Ask client questions to explore possible action, following information	When providing information, questions can be used to explore how the client might apply the information to reach their health-related goals.
Facilitating retention
Use repetition to promote comprehension and retention	Provider uses strategies, such as repetition of content, to make information understandable and memorable.
Use narrative methods to promote comprehension and retention	Provider uses stories to communicate information that is engaging, emotionally evocative, and memorable.
Use materials to promote comprehension and retention	Provider uses teaching materials such as a white broad, handouts, or worksheets; all materials function to vary educational methods and to make information more understandable and memorable.
Closing
Affirm client capacity to use information	Provider is optimistic of the client’s capacity to use the information to meet their goals.
End with a summary of information, and if applicable, action plan	Provider always ends psychoeducation with a summary of the content along with any stated goals and/or action steps.

3. Results

3.1. A conceptual formulation of psychoeducation

To derive a working definition of psychoeducation, we first examined a range of definitions from the extant literature. Perhaps most well-known in the addictions is FRAMES (Bien, Miller, & Tonigan, 1993). The FRAMES model is meant to highlight commonalities of brief interventions, but the combination of educational and relational elements is the reason why it begins our discussion here. That is, a key goal of this review is to articulate relational and other techniques associated with best-practice educational interventions. The FRAMES model, for example, includes: Feedback on the presenting condition, Responsibility for change placed on the client, clear Advice for change from the provider, and a Menu of change options delivered all while communicating Empathy and promoting Self-efficacy. FRAMES is one of the few common factor models in the addictions, and characterizes a number of stand-alone interventions with a central educational component (e.g., Brief Alcohol Screening and Intervention for College Students, Dimeff, Baer, Kivlahan, & Marlatt, 1999; The Drinker’s Check-up, Miller, Sovereign, & Krege, 1988). In these interventions, education comes in the form of assessment-driven feedback on alcohol or other drug consumption patterns, population-based comparators, and use-related consequences. If a moderation or abstinence goal is agreed upon between the provider and client, the provider may provide education on harm reduction and other self-regulatory strategies. Feedback on reported consumption patterns will not only enhance knowledge, but also influence motivation via social comparison with age, gender, and often location-matched peers (Miller, Zweben, DiClemente, & Rychtarik, 1992). This highlights the first key point in our conceptual formulation—the goal of psychoeducational interventions is typically to justify or promote action, and as a result, knowledge is not the endpoint, but one purported mechanism of change.

In describing psychoeducation in mental health, Lukens and McFarlane (2004) note a combination of educational and therapeutic techniques, which are used to promote patient empowerment in managing varied aspects of a disease. In their review of clinical trials, interventions deemed psychoeducation often involved the family and incorporated self-regulatory coping skills such as those from cognitive behavioral therapy. This integrated approach arose via its origins in the deinstitutionalization movement as method of individual, group, and/or family treatment for major mental illness (O’Donohue & Cummings, 2011; Sarkhel, Singh, & Arora, 2020). The United Kingdom’s National Institute of Clinical Excellence (2016) defines psychoeducation as any program that addresses an illness from a multidimensional viewpoint, providing patients and their caretakers with both information and support. Therefore, the field often uses the term psychoeducation as an umbrella term for any number of educational, familial, and/or skills-oriented treatments. This diffusion of the term was exactly the rationale for Goldman’s 1988 paper attempting to identify a definition for psychoeducation and distinguish it from family and other forms of psychotherapy. For Goldman (1988), psychoeducation was in service of treatment and rehabilitation rather than the treatment itself. We similarly seek a narrow definition that emphasizes the process of imparting disease-related information not as a stand-alone intervention, but as an educational strategy utilized in the course of ongoing care.

Psychoeducation as a strategy used in the course of ongoing care may be closer to the general medicine concepts of patient education or informal patient education, than its usage as an umbrella term encompassing a range of stand-alone modalities in mental health. The term patient education is defined as “…a process by which health professionals impart information to patients and their caregivers to improve health status and encourage involvement in decision making related to ongoing care and treatment” (Fereidouni, Sabet-Sarvestani, Hariri, Kuhpaye, Amirkhani, & Kalyani, 2019; p. 1). The purpose of such education has also shifted in recent years, from providing education to enhance compliance, to empowering patients to use their own knowledge and resources to achieve better health (Hoving Visser, Mullen, & van den Borne, 2010). Research defines informal patient education as intentional, but not necessarily structured or planned (Dunn & Milheim, 2017). In these cases, the goal is the same, but the latter may be more of a spontaneous educational encounter arising out of immediate need and/or context. To summarize, we define psychoeducation as a brief process of therapy focused on the communication of varied aspects of disease- and/or treatment-related information. The intent is to provide information, and such information is often used to justify or motivate action. In doing so, knowledge is one purported mechanism, but we would be remiss if we did not also highlight the mechanistic role of expectancy. Specifically, knowledge of one’s condition and its treatment can promote, though also relies upon, a belief in the healing power of the provider as well as that provider’s suggested course of care (Frank & Frank, 1993).

3.2. The principles of psychoeducation

What follows is a description of the key principles derived from the content analysis of source materials. As we noted, we define principles as broader understandings that must be kept in mind when delivering a particular type of intervention, or practice. For psychoeducation, the data pointed to the goals of the psychoeducational endeavor, and the corresponding quality indicators and methodological considerations that should apply. First, psychoeducation is empowering in that the goal of providing information is typically to promote independent action on the part of the client. In fact, some scholars have argued the very definition of “patient engagement” involves participation in their own health care (Gruman et al., 2010). The educational process itself must therefore engender agency, expertise, motivation, and self-efficacy. If the therapist acts as the expert (Martino et al., 2006) or if they lecture or verbally dominate (Carroll, 1998; Miller, 2002), they place the client into a passive role. This role is antithetical to the purpose of psychoeducation. Principles two and three speak more to the nature of the information itself, which should be accurate and understandable, respectively. Very simply, to make use of information, the information must be useful. This might seem obvious, but the health literacy literature underscores that patients’ misunderstanding of health information is the norm, rather than exception (Hersh, Salzman, & Snyderman, 2015; Marcus, 2014; Webber, 1990). Principle four is about being brief. In our previous work on skills training, the recommended time allotted was at least 20 minutes (Carroll, 1998; Kadden et al., 1992) and this is consistent with the adult learning literature with respect to typical attention span (Farley, Risko, & Kingstone, 2013). However, we argue that up to 10 minutes is ideal when strictly information provision is the task at hand (i.e., no subsequent experiential practice component). This estimate is similar to the time allotted for the feedback portion of a 45- to 60-minute brief motivational intervention (Miller et al., 1992).

Principle five reminds the provider that psychoeducation is an interactive process, and this is for good reason. An interactive educational process facilitates empowerment (Miller, 2002), engagement (Epstein & McCrady, 2009; Monti et al., 2002), and understanding and retention (Ekhtiari et al., 2017). Interactive psychoeducation will require principle six, which states that the teaching methods of the provider should be matched to individual needs. These needs include learning and cognitive functioning (Carroll, 1998; Kristiansen, Videbech, Kragh, Thisted, & Bjerrun, 2018; Lasa-Blandon, Stasi, Hehir, Fischer-Cartlidge., 2019), attentional capacity in the moment (Farley et al., 2013), and incorporating varied teaching methods such as verbal, written, visual, tactile, and auditory (Lasa-Blandon et al., 2019). The psychoeducational process should also incorporate the unique cultural worldview and circumstances of the individual or it runs the risk of being essentially irrelevant (Bunge, Mulhauser, & Steckelberg, 2010; CSAT, 2019). In empirical work, an “illness explanation” that was culturally informed explained significant variance in the efficacy of culturally adapted versus un-adapted psychotherapies (Benish, Quintana, & Wampold, 2011). With that said, cultural competence must be undertaken with a high level of humility and nuance as the provider cannot assume that cultural affiliation is the client’s required route to healing (Sue, Zane, Nagayama-Hall, & Berger, 2009).

Principle seven notes that psychoeducation may end with a goal, may facilitate a goal, or in some way promote action. We use the word “may” to highlight that a goal might not be the outcome of every educational encounter, but as noted above, knowledge and expectancy are not the assumed endpoints, but purported mechanisms of behavioral action. As a result, significant care and attention must be given to the persuasiveness of the process. Otherwise we are at risk of perpetuating a key thinking error observed in the health education field:

Over the past quarter of a century the health and medical profession has succumbed to the temptation to deify education, to assume that it automatically improves the quality of lives, yields roused and motivated individuals, and most commonly leaves people with the desire to go home and do exactly what the professional feels is best. The result of all this has been the assumption that medically recommended complex behavior changes can be accomplished through simple educational interventions such as dispensing pamphlets or showing films. (Squyres, 1980; c.f. Webber, 1990)

The final two principles speak to the providers’ qualities and behaviors that are associated with high-quality psychoeducation. For principle eight, we are reminded that psychoeducation requires both teaching and learning facilitation. Teaching involves the direct provision of information that the client or patient is assumed not to have; this may involve lecture, Socratic questioning, and structuring statements to reorient to teaching content. Facilitation, on the other hand, involves more open-ended exploration (i.e., open questions and reflective listening) as well as relational techniques such as affirmation, empathic statements, and statements that promote personal agency. The final principle (principle nine) describes the style of the provider that must harness both of these methods. Because the provision of information creates a top-down dynamic for the encounter, the information provider must be acutely aware of the need for client empowerment (Collins et al., 2018; Marcus, 2014). They must be equipped to deliver the material in a flexible, integrated, and highly engaging manner (Meyers & Smith, 1995), which also requires both expert command of the teaching material and the ability to communicate that material to engender expectation of therapeutic benefit. In the following section, we describe the practices of the psychoeducation (see Table 1 for principles one through nine, with definitions).

3.3. The practices of psychoeducation

Our results found 21 practices of psychoeducation that characterize the how of enacting the nine principles we just described. Specific practices included ways to transition to psychoeducation (e.g., provide rationale and promote expectancy), teaching methods in psychoeducation (e.g., use plain language), tailoring content in psychoeducation (e.g., to learning style, to cultural worldview), and methods for facilitating a dialogue about the information (i.e., five question types), for facilitating understanding and retention of the information (e.g., tailor to individual needs, use of varied teaching modalities), and how to end psychoeducation and engage in related goal-setting, where applicable.

When beginning any psychoeducational encounter, the provider should implement an appropriate transition that reorients the client to a different kind of provider-patient interaction—a teaching interaction. With that said, the difference should not be so abrupt that it feels as if the therapy has ended and the teaching has begun. Some sources (i.e., 10 of 52) identified the need for permission to inform or advise that facilitates the principle of empowerment (principle one; Miller et al., 1992; Miller, 2000, SAMHSA, 2019). This method can be contrasted with simply beginning a lecture sequence without any expressed interest from the client, which places the client into a passive recipient role (Kristiansen et al., 2018). Asking permission is a small gesture with a potentially large impact; it sets precedent that the client has a central role in determining the course of care. Similarly, the rationale should “sell” the value of the information to help the client reach their goals. Of 52 sources, 8 discussed the need for and the nature of this rationale. One source noted a reorienting function of the rationale, stating: “…in order for learning to occur, an individual must be conscious of the need to learn” (David, 2015; c.f. Dunn & Milheim, 2017, p.20). While permission and rationale begin psychoeducation, structuring statements help to maintain focus (12/52 sources; Nowinski. Baker, & Carroll, 1992). Structuring statements provide further rationale, redirection, and/or repetition to allow information to occur via dialogue while ensuring all teaching content is communicated.

A central principle of psychoeducation is that it must be understandable (principle three). What follows are several teaching practices for facilitating this key requirement. These practices include using simple, nonjargon language (14/52, Hersh et al., 2015; Marcus, 2014; Marlatt, 1997), using client language (20/52, Carroll, 1998; Martino et al., 2006; McCrady, 2000), and delivering information at a moderate pace (5/52, Hill, 1997). Ten of 52 sources also discussed providing information in organized units such that comprehension and retention would occur. One method—“chunk, check, chunk”— provides a section of information, engages in a check for understanding, and then transitions to a new section (Hersh et al., 2015). Part of meaningful organization may also include organizing information with increasing difficulty (6 of 52 sources, Monti et al., 2002). Along with the noted universal practices, sources (11/52) also underscored that educational providers must assess client learning needs wherever possible, and adjust their teaching methodology accordingly (Hill, 1997; Lasa-Blandon et al., 2019; SAMHSA, 2019). This matching includes language preference and capitalization on personal cultural experiences and meanings that may facilitate engagement with the learning content (7/52, SAMHSA, 2019). For a couple sources (2/52), adjustment to shifting client engagement indicated via nonverbal cues such as wandering eyes, fidgeting, or leaning away from the provider were also noted (Farley et al., 2013).

Psychoeducation must be interactive (principle five), as only a two-way conversation can facilitate empowerment (principle one) and understandability (principle three). There are numerous types of questions that will facilitate the interactive nature of high-quality psychoeducation. A way to begin is by asking what information the client already has on a given topic; this communicates an assumed level of expertise about their own condition (3/52, Miller et al., 1992). The provider should also communicate the importance of the client’s questions about the learning content. This acknowledgment can occur in two key ways: 1) by asking “what” questions there are instead of “if” there are questions and 2) by suggesting that clients bring planned questions to the session (e.g., “ask me three”). A commonly recommended practice is the use of the “teach back” (13/52, Lasa-Blandon et al., 2019; Zweben, 2000). When using a teach back, the provider will ask the client to explain the concept in their own words, to apply the concept in a personal example, or to review the key points of a given educational discussion. The authors emphasized that the frame should not be a test of client understanding, but a test of the provider’s capacity to effectively teach (Hersh et al., 2015). Finally, open questions about general reactions to the learning content can further a dialogue and may provide a smooth transition to goal-oriented discussions (Miller et al., 1992; Miller, 2002).

The final group of practices can be characterized as a set of teaching and learning facilitation tools that may further client engagement, and thus retention of the psychoeducational content. In the adult learning literature, repetition is a primary route to retention (7/52 sources) and in marketing, the “rule of seven” argues that repetition must be frequent (Hammer & Stanton, 1995, c.f. Marcus, 2014). To be repetitious and engaging simultaneously is an art, and the above noted question practices as well as the use of anecdote or storytelling may be useful (10/52, Ekhtiari et al., 2017). Sources also argued for the need for varied information delivery methods such as worksheets, white boards, or video (15/52 sources, Hersh, 2015; Kadden et al., 1992; Lasa-Blandon et al., 2019). Finally, in the latter moments of the psychoeducational process, the provider should query any action the client plans in response to the information (11/52, Hironaka & Paasche-Orlow, 2008), affirm the client’s capacity to use the information (16/52, Marlatt, 2000), and summarize all information, including the subsequent action plan where appropriate (7/52 sources, Miller et al., 1992).

4. Discussion

Anderson and colleagues first used the term psychoeducation in 1980 to describe interventions that educate those with major mental illness about various aspects of disease, including treatment. From an ethical standpoint, education and information are part of a patient’s right to informed consent to care (Chachkes & Christ, 1996; Dunn & Milheim, 2017). Research has additionally shown that understanding the nature of one’s condition can, itself, be therapeutic (Gold & McClung, 2006). In the addictions, psychoeducation may be used as a standalone intervention or as a part of ongoing treatment, and the latter is how we have emphasized it here. As such, our frame may be more analogous to the concepts of patient education or informal patient education in medicine, which represented 50% of our available sources overall and served as the source of most of our recommendations. This higher relative proportion may have been the result of greater room for change when shifting from a top-down to a more egalitarian approach to education (Virtanen, Leino-Kilpi, & Salanterä, 2007). However, even in general medicine, this is a nascent field with scholars lamenting the lack of available models that focus on the how of information-delivery, rather than the specific information that should be communicated (Geboers, Reijneveld, Koot, & de Winter, 2018). The current review and content analysis is one of very few procedural works on the topics of patient education, information giving, and/or psychoeducation in the addictions, and from this work, some summary considerations emerged.

4.1. Psychoeducation as collaborative teaching

Psychoeducation as a therapy process can be framed as collaborative teaching. The process is collaborative in the sense that educational and relational practices hold equal weight in the encounter. In medicine, this process has been referred to as a combination of “getting it” (i.e., competence) and “getting me” (i.e., warmth; Howe, Leibowitz, & Crum, 2019). We similarly underscore the importance of these relational considerations and suggest they are not a forgone conclusion in many frontline clinical contexts. In fact, research has shown the opposite, where providers favored technique over empathy, at least at early stages of their professional development (Schultze, Mujica, & Kleinheksel, 2019). In some cases, clinicians may be so enamored with their information that they fail to recognize that clients do not share the same affinity or fascination. With respect to substance use, cognitive functioning and/or goal orientation could also be compromised (Potenza, Sofuoglu, Carroll, & Rounsaville, 2011). As a result, we argue that even when in teaching phases of treatment, providers must employ core counseling and facilitation skills to ensure client engagement with the teaching content provided.

4.2. High-quality psychoeducation requires a close consideration of what promotes client understanding

The majority of practices in our results centered on methods to promote client understanding of educational content (e.g., Ekhtiari et al., 2017; Lasa-Blandon et al., 2019; Marcus, 2014). In the health literacy literature, approximately one-third of adults are described as having limited capacity to read, understand, or apply their health-related information (Kutner, 2006). Moreover, both providers and patients may misinterpret their own capacity for understanding (Hersh, et al., 2015). Methods described in our results included how the information should be delivered (e.g., using plain and culturally congruent language, at a moderate pace), the type of questions that should be asked (e.g., a teach back question), and the materials to be used (i.e., including recommended reading levels of fifth-grade or below). Several reviews were dedicated to the characteristics of the teaching materials themselves, which should include both text and visuals (e.g., pictures or graphs), a clear organizational structure, and should avoid technical or esoteric terminology (Albright et al., 1996).

Our results underscored again and again the importance of recognizing that information delivered does not equate information received. The literature recommended several types of open-ended questions. In one of the few information-giving procedural models in the addictions, “elicit-provide-elicit” in motivational interviewing serves several of these functions. The provider first elicits the client’s knowledge of a particular topic (i.e., ask client what they already know about the information), provides further information on the topic, and then elicits the client’s response to the information (i.e., ask questions to explore client reaction to information; Miller et al., 1992). The key functions are engagement, empowerment, and exploration. The teach-back (i.e., ask questions to check understanding of information) is focused on demonstrated understanding. Additional question types where those that provided space for any potential need for clarification (i.e., ask client to ask questions) and potential action steps in response to information (i.e., ask questions to explore possible action, following information). While question functions varied, the theme across source references was that psychoeducation is a structured dialogue and not a one-way lecture.

4.3. Limitations, conclusions, and implications

This literature review and qualitative content analysis yielded nine principles and 21 practices for the conduct of high-quality psychoeducation in evidence-based addictions care. We note some final limitations and conclusions for the reader to consider. The content analysis was a single rater procedure, which reflects an important limitation of this work. However, a review of face validity with an independent rater showed that both principles and practices could be encoded with high agreement. The sample size might also be small in comparison to all possible sources in addictions, mental health, and general medicine. Therefore, we do not know whether a larger sample would have resulted in additional principles and/or practices, and procedures such as a Delphi study could validate or extend these results. With these caveats in mind, this review provides foundation for future work on therapist training and fidelity monitoring of psychoeducation. Combined with our previous work on skills training and future work on relationship building, setting and monitoring treatment goals, and working with naturalistic support systems, a training model on common factor principles and practices in addictions therapy is emerging. In conclusion, we offer a novel resource with pragmatic value to trainees, providers, and clinical supervisors who do not consider themselves aligned with a single evidence-based modality. Instead we speak to integrative and technically eclectic therapists who may benefit from training and proficiency assessment in core, behavioral health counseling competencies.

Highlights.

• The goal of this systematic review and qualitative analysis was to operationalize the cross-cutting process of psychoeducation in work with individuals with alcohol or other drug use disorders.

• Fifty-two source documents (i.e., therapy manuals, literature reviews, and government issued practice guidelines) and videos (i.e., therapy demonstration videos) were examined.

• Nine principles and 21 teaching and facilitating learning skills were identified.

• We frame psychoeducation as a collaborative approach to teaching where client engagement, understanding, and utilization of the information provided is the central goal.

• This work informs a fidelity-based approach to psychoeducation that is applicable to a wide-range of content topics, therapeutic modalities, and implementation settings.