Psychoeducational treatments for obsessive-compulsive disorder: A narrative review emphasizing family-based approaches

Abstract

Psychoeducation is a structured but straightforward and effective treatment, which consists of educating patients and family members about psychiatric disorders, teaching them to cope with the illness, and supporting them during treatment. Psychoeducation as an independent treatment is effective in schizophrenia and bipolar disorder. Psychoeducation is a core component of cognitive-behavioural therapy (CBT) or exposure and response prevention (ERP) treatment, which are the standard psychotherapeutic treatments for obsessive-compulsive disorder (OCD). However, research on the benefits of psychoeducational treatments in OCD is limited compared to schizophrenia and bipolar disorders. Very few studies have examined psychoeducation as an independent treatment for OCD, and its efficacy is not proven. The effectiveness of CBT or ERP for OCD is well established, but the contribution of psychoeducation to the efficacy of these treatments is unclear. Recently, there has been a greater understanding of maladaptive family responses, such as accommodation and antagonism, that worsen the outcome and treatment response in OCD. Family-based psychoeducational treatments targeting inappropriate family responses are effective in reducing obsessional symptoms, attenuating the negative family impact of OCD, and improving patient and family functioning. Family-based psychoeducation is a promising treatment for OCD, but there are methodological issues with the evidence, and trials among adult patients are limited compared to children and adolescents. The other obstacles to the implementation of psychoeducational treatments of OCD are the large treatment gap, lack of research from low- and middle-income countries, and the limited attempts to develop culturally adapted treatments in these countries. Thus, further research should focus on optimising psychoeducational treatments for OCD and efficiently delivering these treatments in routine clinical settings.

Key Words: Psychoeducation; Obsessive-compulsive disorder; Family-based; Accommodation; Expressed emotions

Core Tip: Psychoeducation is a simple and effective treatment with proven efficacy in schizophrenia and mood disorders. Psychoeducation is a core component of cognitive-behavioural therapy or exposure and response prevention, which are the standard psychotherapeutic treatments for obsessive-compulsive disorder (OCD). However, research on the benefits of psychoeducational treatments in OCD is limited compared to other disorders. Maladaptive family responses such as accommodation and antagonism are common in OCD and adversely influence its outcome. Family-based psychoeducation targeting these inappropriate family responses is a promising treatment for OCD, but there are methodological uncertainties. Thus, optimising psychoeducational treatments for OCD remains a challenge.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic and disabling psychiatric disorder with recurrent thoughts or images (obsessions) and repetitive acts (compulsions). The lifetime prevalence of OCD varies from about 1%[1,2] to 2%-3%[3,4] across the world. OCD is the fourth or fifth most common psychiatric disorder in adults worldwide[3]. OCD starts early and remains a lifelong affliction.

The average age of onset is 19 to 20 years[2,4]. The first onset peak is during childhood or early adolescence (7-12 years)[3,5]. There is a second onset peak in early adulthood from 20 to 23 years. The majority of patients (50%-80%) develop OCD before the age of 25 years[2,4,6]. Only about 5% of the patients develop OCD after the age of 35-40 years.

The natural course of untreated OCD is a chronic, continuous one with exacerbations and remissions[5,6]. Spontaneous recovery occurs in about 5%-20% of patients, while a deteriorating course affects about 10% of those with OCD.

Most patients (70%-80%) improve with treatment, but sustained remission is found in only a little more than half of the patients[7]. Complete recovery with treatment occurs in 20%-30% of the patients[6,8].

Individuals suffering from OCD have to endure considerable distress and dysfunction because of their symptoms. OCD is one of the leading causes of disability among all medical and psychiatric disorders[3,5,8]. About two-thirds of the patients have severe impairments in socio-occupational functioning[9]. OCD is also associated with a poor quality of life[3,5]. OCD leads to a high burden of care for the families of the sufferers and society because of the substantial costs of care and losses in productivity in those afflicted[3,8].

Evidence-based treatments for OCD include cognitive-behavioural therapy (CBT) or exposure and response prevention (ERP) treatment, and medications such as selective serotonin reuptake inhibitors (SSRIs) or clomipramine[5,10,11]. These treatments are highly effective, with response rates of 70%-90% in those who adhere to them.

ERP, or CBT, which includes ERP, is slightly more efficacious than medications[5]. Combined treatment with SSRIs and psychotherapy is effective for severe OCD[12]. Nevertheless, about 10%-33% of individuals who complete ERP do not show any benefit from treatment[6,11]. About 25% refuse ERP, and 25% drop out of treatment early. Consequently, only 50% of the patients benefit from treatment and show clinically significant gains[6,13].

However, the bigger problem is inadequate access to proper treatment for OCD. The gap between those requiring treatment and those receiving treatment is estimated to be about 50% across different countries[14]. Even in resource-rich countries, about 60%-70% of the patients remain untreated or receive inadequate treatment, and less than 10% receive CBT or ERP[5,15]. The treatment gap is larger in less developed countries, with only 10%-15% of the patients having access to any treatment, SSRIs, or CBT or ERP[14,16]. The lack of specialised treatment resources for OCD and unawareness and stigma among patients and families are the principal reasons for this treatment gap[5].

Psychoeducational treatments can enhance access to treatment for OCD by improving awareness of the disorder, the availability of effective treatments, and reducing the stigma associated with seeking treatment for OCD[14,17].

Psychoeducation is a simple but effective treatment, which consists of educating patients and family members about psychiatric disorders, teaching them to cope with the illness, and supporting them during treatment[18,19]. Psychoeducation can be used as an independent psychotherapeutic treatment or as a part of more complex psychotherapeutic interventions[17,18,20].

Psychoeducation is considered a core component of CBT or ERP for OCD, which uses psychoeducation in conjunction with other techniques[11,21]. Research on the benefits of psychoeducational treatments in OCD is limited compared to schizophrenia and bipolar disorders[17,21]. Very few studies have used psychoeducation as an independent treatment for OCD[22,23]. However, there has been progress in understanding the impact of OCD on the family and unhelpful family responses[22-24]. This understanding has led to the development of a new set of family-based psychoeducational treatments targeting inappropriate family responses, which appear to be promising treatments for OCD.

Aims and objectives of this review

Aim: This review aims to synthesise the current evidence on psychoeducation as an independent and adjunctive treatment for OCD.

Objectives: (1) To examine psychoeducation's theoretical foundations, formats or models, and effectiveness; (2) To determine the relevance of the principles of psychoeducation for the treatment of OCD; (3) To evaluate the effectiveness of psychoeducational treatments for OCD; and (4) To identify the gaps in research and challenges in implementing psychoeducational treatments for OCD.

DEFINING PSYCHOEDUCATION

Psychoeducation is a systematic and structured psychotherapeutic intervention that includes didactic elements for imparting information about the illness, psychological elements to enhance coping with the demands of the disease, and supportive elements that help those afflicted while undergoing treatment[18,19,25-27].

Simple psychoeducational treatments consist of purely didactic techniques for conveying information about the illness. More complex psychoeducational interventions include two-way communication and mutual exchange of information to improve illness-management skills[23,26,28].

Most definitions of psychoeducation include individual psychoeducation with patients and family-based psychoeducation for relatives of patients[25,27,29-31]. Narrowly defined psychoeducation includes "education or training of a person with a psychiatric disorder in subject areas that serve the goals of treatment and rehabilitation"[32,33]. Narrow definitions do not include psychoeducational family treatments unless the family member suffers from a psychiatric disorder.

Despite the differing definitions, there is considerable agreement about the goals of psychoeducational treatment[19,25,29,31]. The following section discusses these goals.

GOALS AND PURPOSES OF PSYCHOEDUCATION

Despite the wide variations in techniques, psychoeducational treatments share common goals. Table 1 elaborates on these goals[34-42].

Table 1 The goals and purpose of psychoeducation.

Goals/purpose	Explanation
Improving understanding of the illness	Psychoeducation aims to improve the patient’s and families’ understanding of the illness. The purpose of imparting information is to promote awareness as well as acceptance of the illness. Education about the illness paves the way for other purposes of psychoeducation including promoting empowerment, improving coping and self-management skills, enhancing treatment seeking and treatment engagement, instilling hope, reducing stress, alleviating feelings of isolation and stigma, and aiding recovery. Awareness about the illness promotes tolerance of the illness among family members, reduces family conflicts, and improves family support[17-19,29,34]
Promoting empowerment	Psychoeducation is empowering because it emphasizes the fundamental right of individuals to be informed about their illnesses. Psychoeducation empowers patients and families by providing a realistic appraisal of the consequences of the illness and the difficulties they face in life. Psychoeducation restores the patient’s independence, self-esteem, and dignity. Psychoeducation enables patients to manage the effects of the illness in a proactive manner, focuses on developing collaborative and trusting treatment relationships, and allows patients and families to actively participate in the treatment. Empowerment is associated with improvements in mental wellbeing, and personal and family functioning[17,19,35-37]
Enhancing the patient’s and family’s ability to cope with illness	Psychoeducation provides the means to manage, cope, and live with a chronic psychiatric disorder. Enhancing coping improves the acceptance of the chronic nature of the illness for patients and families. Organizing the subjective perceptions and experiences of patients and families objectively helps in developing adaptive attitudes and behaviours and inculcates a sense of mastery over the illness. The ability to deal with the stresses and strains of the illness develops with time. Families learn skills to deal with the patient’s problems similar to the ways that professionals handle these demands. Improved family coping reduces conflicts and improves family functioning. Improved awareness and belief in the ability to cope with the illness reduces stigma, improves motivation, encourages treatment seeking, and promotes treatment engagement[19,34-36,38]
Provision of emotional and practical support	Psychoeducation provides support for patients and their families. Emotional support is provided to the individual to deal with the stressful consequences of the illness. Practical support or tangible assistance is often necessary for patients to improve resilience and handle the demands of the illness. Group support helps reduce the feelings of isolation, despair, low self-esteem, and stigma. Families need emotional support to deal with psychological consequences of the patient’s illness. Practical support is provided to families by informing them of resources such as groups or organizations. Efforts are made to increase their social network by increasing interpersonal, social, recreational, and health-service contacts of the families. Supportive interventions are associated with better treatment outcomes, increased wellbeing, and improved patient and family functioning[27,29,30,34,38]
Achieving recovery	The goals of treatment of mental illnesses have gradually shifted from clinical, to functional, and social recovery. The goals of psychosocial treatment have similarly moved from achieving clinical remission and relapse prevention to supporting and sustaining functional and social recovery. The focus is on creating the optimal environment in which the patient can achieve recovery and helping families to contribute to the patient’s recovery[30,39-42]
Reducing stress and improving functioning	Psychoeducation aims to reduce stress in patient and the family through behavioural and supportive methods. Resilience to stress is built by imparting information and teaching skills to deal with the illness-related stressors. Supportive techniques are used to promote adaptive and improved functioning of the individual and the family. Supportive family environments can help the patient achieve recovery[17,27,34,36,38]

FUNDAMENTAL PRINCIPLES OF PSYCHOEDUCATION

Psychoeducation is one of the simpler psychotherapeutic treatments[19]. It fits all the attributes of psychotherapeutic interventions, such as teaching, skill development, and alliance formation[18,32]. Similar to other psychotherapies, psychoeducation exerts its effects through cognitive mastery and affective and behavioural regulation[32]. Psychoeducation is a structured treatment with a systematic approach, goals, and principles. These unique goals and principles differentiate psychoeducation from the more traditional forms of complex psychotherapies[43]. Table 2 summarises the fundamental tenets of psychoeducational treatments[44-53].

Table 2 The fundamental principles of psychoeducation.

Principles	Explanation
Simple form of psychotherapy	Unlike the more complex or “skilled” psychotherapies, psychoeducational treatments are a simpler form of psychotherapy. Psychoeducation is not based on an elaborate theoretical framework. Psychoeducation is easily understood by clinicians, patients, and their families. The techniques used are simple and do not require extensive training. The person providing the treatment needs to have expertise and experience in dealing with psychiatric disorders and the basic skills for conducting psychotherapy. Psychoeducation is traditionally delivered by trained mental health professionals, but models using peer education are also effective. Psychoeducation can be used in different clinical and non-clinical settings. Psychoeducation has specific and modest goals. Psychoeducation is an easy-to-administer and relatively inexpensive form of treatment. Psychoeducation is usually more accessible than complex psychotherapies[19,35,36,44,45]
Structured form of psychotherapy requiring several skills	Psychoeducation is also a highly structured form of therapy. Research suggests that structured and evidence-based psychoeducational treatments are more effective than unstructured interventions. Psychoeducation integrates educational, behavioural, cognitive, and supportive techniques. The skillful delivery of psychoeducation requires that the therapist be conversant with health education techniques, proficient in teaching coping strategies, and have the ability to foster alliances through support and empathy[19,32,44,46]
Flexible treatment with diverse uses	Although psychoeducation is a structured form of therapy, it incorporates a degree of flexibility and sensitivity to the needs of the patients and their families. The simplicity and flexibility of psychoeducation ensure that it is useful in many psychiatric disorders and in community, outpatient, day-care, and inpatient settings. Psychoeducational treatments can be tailored according to the phases of the illness. Cultural adaptations are also possible. In theory, it should be easier to disseminate and implement psychoeducation than more complex interventions. However, in practice, there are several barriers to the dissemination and implementation of psychoeducation in clinical settings[20,31,33,34,47]
Core component of treatment	Psychoeducation is a core component of most psychotherapies. Psychoeducation forms a part of the routine management of all psychiatric disorders. Medications, psychoeducation, and more complex psychotherapies are the three principal elements of treatment for all psychiatric disorders[21,48]
Adjunctive treatment	Psychoeducation was developed as an adjunct to medication treatment particularly in severe mental illnesses. As an adjunctive treatment, the principal goal of psychoeducation is to improve medication adherence. Psychoeducation also addresses the domains of functional impairment and interpersonal problems that are not addressed by medications. The combination of medications and psychoeducation is often better than either treatment delivered alone. The efficacy of psychoeducation results from a synergistic combination of pharmacological, psychotherapeutic, and social approaches[17,18,40,49,50]
Patient-centredness, collaboration, and shared decision-making	Psychoeducation follows a patient-centred approach in which consideration is given to patients’ and families’ views and preferences about treatment. Psychoeducation is based on an equal partnership and collaboration between professionals with illness expertise and patients and families with personal expertise. Decisions about the treatment are the outcome of open discussions between professionals, patients, and families. A “teamwork” approach is followed, in which patients, families and professionals share a common understanding of the disorder and its treatment. The collaborative, person-centred, and shared-decision making approaches are useful in fostering strong treatment alliances, which are a fundamental component of psychoeducation[11,20,31,36,51]
Positive orientation	Psychoeducation aims to instill hope and optimism about the outcome of treatment in patients and families through improvement of awareness and social interactions. Patients are encouraged to believe that they can lead productive lives despite the negative impact of the illness on their lives. Psychoeducation uses a “no fault” approach by avoiding blaming either the patient or the family for the illness. Psychoeducation replaces the feelings of despair, fear, stigma, and low self-esteem with optimism and increased self-worth, and encourages patients and families to be active partners rather than passive recipients of treatment[18,19,21,34,52]
Normalization	Psychoeducation attempts to normalize the patient’s symptoms and dysfunction by focusing more on the healthy aspects of the person’ functioning and attempting to reach an optimal level of functioning rather than curing the illness[21,32,43]
The positive cycle of treatment engagement and psychoeducation	Information about the illness leads to the understanding that it is a treatable condition. This persuades patients and families to commit to long-term treatment and their motivation for treatment is enhanced. Treatment engagement and adherence is one of the principal tasks of psychoeducation. Treatment engagement creates a positive cycle - adherence reduces symptoms and allows the patient to take part in psychoeducation, which in turn facilitates subsequent adherence[17,18,21,35,36]
Medical model and biopsychosocial approach	In clinical settings, psychoeducational treatments follow a medical model by considering all psychiatric disorders to be primarily caused by abnormalities of brain structure and function. In other settings, the predominant approach is a biopsychosocial one. The biopsychosocial approach is more holistic and competence-based, treats the person as a whole, and considers individual strengths and weaknesses. Psychoeducation focuses on the present and avoids delving in the past[19,20,31,34,38]
Stepped care approach	Psychoeducation follows a stepped care approach, where the treatments proceed from simple to more complex techniques, and from stand-alone psychoeducational treatments to psychoeducation integrated with other psychotherapeutic interventions[29,53]

THEORETICAL BASIS OF PSYCHOEDUCATION

Theoretical models

There are two main models of psychoeducation, with the biopsychosocial approach being the most commonly followed. The diathesis-stress theory, which underlies this model, emphasises the contributions of biological, psychological, and social factors to mental illness[18]. The diathesis-stress theory suggests that psychiatric disorders arise from interactions between biological vulnerabilities (such as brain abnormalities and genetic predispositions), psychological processes (like maladaptive cognitive styles), and social factors (including stressful life events and dysfunctional family environments)[30,45].

The biopsychosocial approach is holistic and patient-centred, considering the patient's strengths and weaknesses[20,38]. It aims to enhance awareness, empowerment, coping, self-care, and support for patients and their families. Psychoeducational treatments prioritise current challenges and do not delve into the past, nor do they assume that family pathology is the root cause of psychiatric disorders[30].

Psychoeducation also adheres to the medical model because it avoids blaming patients or families for the illness[19]. The medical model is focused on the clinical realities of psychiatric disorders and has a simple and easy-to-follow framework that allows psychoeducation to be delivered effectively.

The choice of model often varies by the professional conducting the treatment[34]; psychiatrists and nurses are more inclined to follow the medical model, while psychologists and social workers typically embrace the biopsychosocial model.

Theoretical approaches

A range of theories underpin the psychoeducational approach. The principal theories that inform psychoeducational treatments are cognitive-behavioural, supportive approaches, humanistic approaches, health education, social learning, and crisis theories[18,20,34-36].

The cognitive-behavioural framework serves as the cornerstone for psychoeducational treatments[18,20,34]. Cognitive-behavioural techniques of psychoeducation aim to help patients and families develop a sense of cognitive mastery over the challenges posed by the illness[34]. These techniques involve imparting basic information and developing coping skills. Cognitive-behavioural techniques focus on changing cognitive biases, building coping abilities, and enhancing resilience to the stresses associated with illness. Achieving these goals involves enhancing problem-solving, self-assertiveness, and stress management skills, and implementing healthy lifestyle interventions[18,36,38].

Elements of supportive psychotherapy based on client-centred and humanistic approaches are also used in psychoeducation[18]. Supportive techniques are necessary for building strong therapeutic alliances and imparting personalised information tailored to the specific needs of patients and families at the start of psychoeducation.

Social learning theories emphasise the role of social interactions, especially within families, in delivering psychoeducational treatments[35].

Health education theories accentuate the educational aspects of psychoeducational interventions and emphasise teaching and training of illness-management skills[32,43]. Crisis intervention is a crucial part of psychoeducational treatments and equips patients and families with the skills to recognise relapses and respond effectively to crises[36].

ESSENTIAL ELEMENTS OF PSYCHOEDUCATION

The three essential components of psychoeducational treatments are imparting information, enhancing coping competence, and forging treatment alliances with patients and families[17,18,20,34,54]. Table 3 Lists the essential elements of psychoeducation and the techniques used to deliver these components[54-64].

Table 3 The essential elements of psychoeducation.

Elements	Techniques and uses
Imparting information	The objective is to provide patients and families with information about the illness and its management[29,34]
	Comprehensive information about symptoms, causes, treatments, and the prognosis of the illness is provided
	Misconceptions about the illness are corrected[17]
	The impact of the illness on the patient’s behaviour is also discussed[18]
	Knowledge-based competence allows patients and families to cope with the consequences of the illness and improves their engagement with treatment[18,34,54]
	Conveying information also aids the development of adequate treatment alliances[55]
	Informing patients and families about the illness is usually a two-step process. The first step consists of conveying information that is universal and common for all patients and families
	A series of structured lectures is used to convey such information as efficiently as possible[18,20,34,54]
	The most effective way to convey the basic information about the illness is by utilising psychoeducational groups[17,18,20,34,54]. Groups also help in providing support, reducing feelings of isolation, and normalising the experience of the illness
	Cognitive-behavioural techniques are utilised for this stage[18]
	The methods to convey information are didactic, explicit, and standardised[17,18,56]
	The next step is to provide information specific to the patient and the family that is tailored to their circumstances[18,21]. This is usually done on an individual basis and utilises supportive techniques[18]. Didactic lectures eventually give way to a two-way communication pattern at this stage
	The information is conveyed in the simplest manner by avoiding professional jargon as much as possible[17,18]
	Written sources of the informational material are almost always required[17,34,38,54]. Different formats, such as face-to-face contact, films or videos, self-help manuals, or digital modes, can be utilised
	The information should be in the local language and adapted to the social and cultural backgrounds of the patients and their families[33]
Enhancing coping skills	The information provided during the initial phases of psychoeducation is used as a basis for teaching specific management skills for patients and families as they deal with the illness[18,20,34,38]
	Cognitive-behavioural techniques of role-play and modelling are employed to teach coping skills[20,57]
	Cognitive-behavioural techniques are also used to enhance the presentation of information by allowing people to rehearse, review and integrate the information taught[34]
	Stress management and promotion of healthy lifestyles are encouraged as techniques to improve coping with the illness[20,38]
	Informational and emotional support are also provided to enhance the learning of coping skills[39,41,48]
	The areas addressed include day-to-day survival skills, common emotional responses to the illness, family atmosphere and conflicts, dealing with illness-related crises, and coping with stigma[39,41,51,57-59]
	Psychoeducational treatments teach problem-solving and communication skills, and the use of resources during periods of crisis[20,39,41,57,60]
	The eventual goal is to transform patients into experts in dealing with their illnesses and for family members to learn to act as “co-therapists” working on equal footing with professionals[18]
	The enhanced ability to cope with the illness can positively influence attitudes and behaviours towards the illness and its treatment, promote active participation in the treatment, enhance the motivation for treatment, and improve engagement with the treatment[18,34,40]
Fostering treatment alliances	The treatment alliance is the most crucial part of psychoeducation[18,21]
	It forms the basis for delivering the other two components of information giving and enhancing coping competence[18,55]
	The alliance is founded on mutual trust rather than the clinician’s authority[19]
	The other components of an effective alliance are collaborative relationships between clinicians, patients and families (mutual agreement on goals and tasks of treatment and emotional bonding), a patient-centred focus, shared decision-making, open communication, confidence in the therapist, support, and stability and continuity of the treatment relationship[19,61-63]
	Client-centred therapy techniques such as empathy, unconditional positive regard, and genuineness are used to build alliances with patients and families[18,21]
	Empathic listening counteracts the dysfunctional cognitions while accepting feelings of uncertainty and demoralisation[18]
	Providing emotional support and promoting stability in treatment relationships also builds strong alliances[18,38]
	The holistic approach followed treats patients and family members with respect and dignity and considers their strengths and weaknesses[38,63]
	Patients and families are viewed as invaluable allies who work with the clinicians to share the burden of managing the illness and moving towards patient recovery[18,64]
	Instilling hope, providing reassurance, and not blaming the patient or families for the illness are the other important aspects of an effective alliance[18,63]

CONTENT OF PSYCHOEDUCATIONAL TREATMENTS

The content of psychoeducational treatments reflects the essential elements of psychoeducation. Table 4 depicts an example of the typical contents of psychoeducational interventions[18,39,54,58,65].

Table 4 The content of psychoeducational treatments.

Topics covered	Details
Engagement	Engaging patients and families using a "no fault" or "no blame" approach attached to the illness
Information about the illness	Symptoms, signs, causes, course of the illness. Dispelling misconceptions about the illness. Explanations about the diathesis-stress model
Information about treatment of the illness	Medication and psychosocial treatment options available. The benefits of treatment. The efficacy of combined medication and psychosocial treatments. How to obtain treatment. Components of psychosocial treatments. Side effects of treatment. The possibility of long-term treatment. Need for treatment adherence and engagement. Expected outcome of treatment
Coping skills	Day-to-day survival skills. Self-management skills. Coping with negative feelings of demoralization, low self-esteem, isolation, helplessness, shame, and stigma
Problem-solving training	Identification of common problems such as medication refusal or disruptive behaviour. Clarification of causes and consequences of problem behaviours. Helpful strategies to effectively combat problems
Communication training	Awareness about negative emotions, distorted cognitions and disturbed communication patterns. Training in adaptive communication styles. Improving ways of providing positive and negative feedback
Improving support	Provision of practical support from professionals, self-help organizations, and peers. Promotion of social, recreational, and occupational contacts to expand the social network
Stress management	Education about the effects of stress on the illness. Learning techniques to reduce stress in patients and families. Adopting healthy lifestyles
Detection and prevention of relapse	Identifying early warning signs of relapse. Accessing resources to deal with relapses. Understanding that exacerbations and remissions are an inevitable part of the illness. Treatment cannot cure the illness but is effective in preventing relapses
Moving towards recovery	A stepwise plan arrived at by patients, families, and clinicians for reintegrating the patient into family and community life

FORMATS AND MODELS OF PSYCHOEDUCATIONAL TREATMENTS

Different formats and models of psychoeducational treatments have been developed based on the common elements of psychoeducation. Most of these models have been used originally for schizophrenia and subsequently applied to bipolar disorders, depressive disorders, OCD, anxiety disorders, posttraumatic stress disorder, substance abuse disorders, childhood disorders, and eating disorders[17,31,36,41,66].

Psychoeducation can be the only component of psychotherapeutic interventions, or more complex psychotherapeutic interventions, such as CBT, may include psychoeducation[17,18,20,54].

Psychoeducation as an independent treatment added to medication regimens has consistently improved the treatment outcomes among patients with schizophrenia and mood disorders. However, psychoeducation as an independent treatment appears to be ineffective in other psychiatric disorders, although the literature on this aspect is not adequate to reach firm conclusions[17].

Psychoeducation is commonly used in CBT, interpersonal psychotherapy, social skills training, and cognitive remediation[11,17,18,50,67]. The combination is equally or more effective than psychoeducation as an exclusive treatment.

Psychoeducation can focus on patients or their families[20,34,36,54]. Family-based psychoeducation includes patients and families. Trained professionals conduct family-based psychoeducational treatments. Lay people, either patients or their family members, conduct family or peer education groups. Family psychoeducation utilises single families or groups of multiple families[36]. Multi-family-based psychoeducational groups are one of the most effective forms of psychoeducational treatment. There is increasing evidence for the efficacy of multi-family-based psychoeducational groups in schizophrenia, mood disorders, and OCD[21-24].

Finally, psychoeducational treatments can last briefly or several months[31,65]. Table 5 shows the different formats and models of psychoeducational interventions for schizophrenia and bipolar disorder[68-75]. Later sections discuss the treatment models for OCD.

Table 5 Formats and models of psychoeducational treatments.

Formats/models	Details
Psychoeducational interventions with patients
Individual psychoeducation for patients	Psychoeducational treatments conducted with individuals with the illness[68,69]
Group psychoeducation for patients	Psychoeducational treatments conducted with individuals with the illness in group formats[68,69]
Brief psychoeducation	Psychoeducational treatments lasting for less than 10 sessions and 3-4 months[70]
Psychoeducational interventions with families
Behavioural family management	A family-based approach including psychoeducation, structured problem solving, and communication training[31,71]
Family-focused therapy	A family-based treatment for bipolar disorder modelled on the behavioural family management. Consists of psychoeducation, communication enhancement training, and problem-solving skills training[72]
Family psychoeducation	A model that involves connecting with the family, providing illness education, and ongoing support and crisis intervention during treatment[31,71]
Relatives’ groups	Relatives’ groups providing education and teaching coping skills for patients and families. Relatives’ groups without patients providing support and problem-solving for the family[31,71]
Multi-family psychoeducational groups	Multi-family psychoeducational groups are conducted with several families simultaneously. Consists of engagement, psychoeducation, problem-solving training, teaching coping skills, and supporting families[31,71,73]
Professional family education programmes	Family education programmes do not involve the patient and do not focus on patient outcomes. The focus is on information and support for families and their well-being and functioning. Family education programmes are run by professionals[25,31,71]
Family consultation treatments	An individual family psychoeducational treatment where the family meets with a consultant (professional or peers). Education, advice, and support are provided according to the family’s needs[31,71,74]
Peer-led family education treatments	Psychoeducational treatments for families conducted by family members of other patients or persons with mental illnesses. Consists of education, teaching emotional coping, problem-solving, communication, and self-care skills. Includes advocacy for patients and their families[31,71,74]
Crisis-orientated individual psychoeducation	Outpatient-based crisis intervention sessions for patients and families[75]
Modified forms of more traditional family therapies	Modified forms of systemic family therapy[30]

EFFICACY OF PSYCHOEDUCATIONAL TREATMENTS

There is a large body of evidence for the efficacy of psychoeducation in schizophrenia, followed by bipolar disorder. The proof of the efficacy of psychoeducation in depressive disorders is relatively scarce.

Table 6 includes the evidence of the effectiveness of psychoeducation from selected meta-analyses and systematic reviews of schizophrenia, bipolar disorder, and depressive disorders[76-110]. Later sections discuss the efficacy of psychoeducation for OCD.

Table 6 Efficacy of psychoeducational treatments.

Outcome parameters	Selected meta-analyses and systematic reviews
	Schizophrenia	Bipolar disorder	Depressive disorders
Prevention of relapse or re-hospitalization	Pfammatter et al[76], Pharoah et al[77], Lincoln et al[78], Bighelli et al[79], Rodolico et al[80]	Bond et al[26], Miklowitz et al[81], Chatterton et al[82], Lam et al[83], Miklowitz et al[84]
Symptom reduction	Zhao et al[70], Lincoln et al[85], Xia et al[86], Asher et al[87], Mc Glanaghy et al[88]	Bond et al[26], Gonzalez-Pinto et al[45], Swartz et al49], Miklowitz et al[81], Chatterton et al[82]	Donker et al[44], Cuijpers.[89], Bevan Jones et al[90], Katsuki et al[91], Tursi et al[92]
Improved socio-occupational functioning	Pharoah et al[77], Lincoln et al[85], Asher et al[87], De Silva et al[93], Bighelli et al[94]	Swartz et al[49], Batista et al[59], Chatterton et al[82], Reinares et al[95], Reinares et al[96]	Bevan Jones et al[90], Tursi et al[92], De Silva et al[93], Brady et al[97]
Improved treatment adherence	Pfammatter et al[76], Lincoln et al[85], Xia et al[86], Mari et al[98], Pilling et al[99]	Bond et al[26], Levrat et al[50], Batista et al[59] , MacDonald et al[100], Demissie et al[101]	Bevan Jones et al[90], Tursi et al[92]
Wellbeing, satisfaction, quality of life	Xia et al[86], Pekkala at al[102]	Bond et al[26], Gonzalez-Pinto et al[45], Levrat et al[50], Miklowitz et al[81], Demissie et al[101]	Brady et al[97], Bevan Jones et al[90], Mhango et al[103]
Improved insight, knowledge, awareness about the illness, and attitudes to treatment	Pfammatter et al[76]	Bond et al[26], Levrat et al[50], Batista et al[59], Demissie et al101], Rouget et al[104]	Bevan Jones et al[90]
Reduced caregiver burden and psychological distress	Cuijpers[105], Yesufu-Udechuku et al[106], Sin et al[107], Claxton et al[108]	Soo et al[109]	Tursi et al[92]
Reduced expressed emotions	Pfammatter et al[76], Pharoah et al[77], Mari et al[98], Sin et al[107], Claxton et al[108]	Reinares et al[95], Reinares et al[96]
Reduced stigma	Alhadidi et al[110]	Levrat et al[50], Demissie et al[101], Soo et al[109]

There is limited evidence for the effectiveness of psychoeducation in substance use disorders, personality disorders, eating disorders, and attention deficit and hyperactivity disorders[17,20,54].

PSYCHOEDUCATION FOR OCD: GOALS, PRINCIPLES, ESSENTIAL ELEMENTS, AND DELIVERY

The goals, principles, central components, and content of psychoeducation for OCD are similar to psychoeducational treatments for other psychiatric disorders, as outlined in Tables 1, 2, 3 and 4.

Figure 1 illustrates the application of these constituents to psychoeducation for OCD[111-122]. One strategy often employed is delivering brief education sessions before the commencement of CBT or ERP. Table 7 provides the rationale for brief psychoeducation and an example of the content of brief psychoeducational treatment for OCD. The efficacy of psychoeducation in OCD depends on the proper implementation of these key ingredients of treatment.

Figure 1 Psychoeducation for obsessive-compulsive disorder: Goals, principles, and essential elements. CBT: Cognitive-behavioural therapy; ERP: Exposure and response prevention.

Table 7 The content of brief psychoeducation for obsessive-compulsive disorder.

Topics covered
1 What is OCD or obsessive-compulsive disorder? What are obsessions and compulsions?
2 How common is OCD?
3 How does the patient feel while experiencing OCD?
4 How do people develop OCD?
5 How is OCD treated? How effective is the treatment?
6 What are the medications used to treat OCD?
7 What is CBT and ERP treatment for OCD?
8 How effective and safe is CBT/ERP?
9 How is CBT/ERP carried out?
10 How long will the treatment take?

Brief psychoeducation consists of brief education sessions delivered before the commencement of exposure and response prevention (ERP) or cognitive behavioural therapy (CBT)[11,21,111,119,121]. Early education about obsessive-compulsive disorder allows the patients and families to make decisions about treatment based on the evidence. It helps to motivate patients and families and prepares them to tolerate the anxiety that may arise from exposure sessions. Once patients begin ERP or CBT, more detailed psychoeducation takes place over several sessions. Detailed psychoeducation continues throughout the treatment and during the stage of relapse prevention. CBT: Cognitive behavioural therapy; ERP: Exposure and response prevention; OCD: Obsessive-compulsive disorder.

Psychoeducation can be a stand-alone treatment for OCD, but CBT or ERP for OCD commonly includes psychoeducational strategies.

PSYCHOEDUCATION AS AN EXCLUSIVE TREATMENT IN OCD

Research on the benefits of psychoeducational treatments in OCD is limited compared to schizophrenia, bipolar, and depressive disorders[17,21]. Very few studies have examined the efficacy of psychoeducation as a stand-alone intervention in OCD[22,23,123].

Table 8 includes the studies of OCD that have examined the benefits of exclusive psychoeducational treatment[124-129].

Table 8 Psychoeducation as an exclusive treatment in obsessive-compulsive disorder.

Ref.	Intervention	Content about OCD	Results
Tynes et al[124]	10-week psychoeducational support group for 21 adult patients and families	Symptoms, diagnosis, assessment, aetiology, ERP, medications, and prognosis	Participants’ evaluation of treatment on a self-designed scale. The intervention was feasible and satisfaction among users was high
Siegmund et al[125]	One-week computerized psychoeducational intervention in 21 patients aged 19-55 years	3 modules on symptoms, aetiology, and the role of CBT	Reductions in YBOCS scores and subjective ratings of depression and anxiety. Feasibility, ease of use, and participant satisfaction were adequate to high
Shishikura et al[126]	Retrospective study of 214 adult outpatients, 64 received psychoeducation for self-ERP, 77 treated with conventional ERP, 18 did not receive ERP	The Four Steps programme of self-ERP	Outcome on GAF and CGI-I scales showed that 46% of the self-ERP group improved compared to 53% of the conventional ERP group
Dissanayake and Drummond[127]	Adult inpatients with contamination fears (number not stated)	3 sessions of psychoeducational group treatment in addition to ERP	Psychoeducational treatment was acceptable and useful in refractory OCD
Mahmoodabadi et al[128]	12-week, controlled study of a psychoeducational support group for 30 adult Iranian patients and families	The study group (n = 15) received eight educational sessions about OCD; the control group (n = 165) did not receive psychoeducation	Significant reduction in the YBOCS scores and significant improvements in family functioning (FAD scale) in the study group
Simsek et al[129]	12-week CBT-based controlled psychoeducational study in 30 adolescents with OCD	Aetiology, symptoms, details of CBT, and the rationale for CBT	Significant reduction in OC symptoms on the Child Version of the Obsessive-Compulsive Inventory. Qualitative data confirmed the efficacy of the intervention

CBT: Cognitive behavioural therapy; CGI-I: Clinical Global Impression Improvement; ERP: Exposure and response prevention; FAD: Family Assessment Device; GAF: Global Assessment of Functioning; OCD: Obsessive-compulsive disorder; YBOCS: Yale-Brown Obsessive-Compulsive Rating Scale.

Although these studies of OCD have shown the benefits of exclusive psychoeducation in terms of feasibility, acceptability, symptom reduction, and improvements in family functioning, their methodology is not adequate to derive firm conclusions about the efficacy of psychoeducation as an independent treatment for OCD.

PSYCHOEDUCATION AS A PART OF CBT OR ERP FOR OCD

Psychoeducation is more commonly an integral part of CBT or ERP for OCD[11,21,113,117,118]. CBT or ERP consists of five elements-psychoeducation, monitoring of symptoms (by patients, families, and clinicians), anxiety management (relaxation exercises), ERP sessions, and cognitive restructuring or processing[11,117,130].

Processing is an important psychoeducational strategy used as a part of ERP. Post-session processing consists of discussions about the patient's and family members' experience of the ERP sessions and how this experience compares with their expectations about ERP[130-132]. Processing also enhances patients' and families' understanding of ERP and provides interactive learning opportunities. Processing addresses the reality of the patient's beliefs about OCD. Corrective information provided during processing can reduce the dysfunctional cognitions associated with OCD. Processing includes discussions about maladaptive neutralising strategies and their role in maintaining symptoms. The explanations given for neutralisations help to counteract such maladaptive coping strategies. Instead, patients are encouraged to use more adaptive coping strategies to cope with their symptoms. All these measures contribute to improved coping skills.

FAMILIES OF PATIENTS WITH OCD

There has been growing awareness and understanding of the impact of OCD on the families of sufferers and the maladaptive responses of family members toward the patient with OCD[22-24]. This understanding has led to the development of family-based psychoeducational treatments, which attempt to reduce these maladaptive responses and improve the outcome of OCD.

THE IMPACT OF OCD ON THE FAMILY

OCD has a considerable impact on its sufferers because of its troublesome symptoms. Simultaneously, the patient's family is also affected. The adverse effects of OCD on the family are typically bidirectional[22,23,133,134]. OCD negatively impacts the family, while family dysfunction and maladaptive family responses adversely affect the outcome of OCD in patients.

Caregiver burden and psychological distress

OCD is associated with a higher burden of care among families. Studies have estimated that 75%-90% of the caregivers of patients with OCD experience disruption in the areas of interpersonal relationships, social and leisure activities, and financial situations[22-24,135]. The rates of psychological distress among caregivers are similarly elevated, with 60%-90% of the family members reporting feelings of frustration, anger, and guilt.

Impaired family functioning

OCD impairs family functioning in several ways[22-24,111,136]. About half or more of the families report impairment in functioning[22,24]. The domains affected are family and social relationships, performance at work, role functioning, problem-solving, and emotional and behavioural regulation[22,135,136].

Caregivers' quality of life

As a result of the high caregiver burden and disrupted family functioning, the quality of life of families of patients with OCD suffers greatly[23,135]. The rates of family burden and poor quality of life in OCD are similar to those reported for schizophrenia[135,137].

Correlates and consequences of adverse family impact

The impact on the family is greater if the patient has more severe OCD[134]. The effect also differs between children, adolescents, and adults with OCD[134]. Higher levels of family impairment are associated with worse illness outcomes and poor treatment response[111].

Thus, the existing evidence indicates that OCD affects the families of sufferers in many ways. It increases caregiver burden and distress and disrupts family functioning, leading to poor quality of life for caregivers. Therefore, CBT or ERP needs to involve families, and family-based psychoeducation needs to address the negative impact of OCD on families.

MALADAPTIVE RESPONSES OF FAMILIES TO OCD: FAMILY ACCOMMODATION

Definition

Family accommodation refers to the familial responses that are related to obsessional symptoms or compulsive rituals[23,24,135]. In accommodation, family members give in to the patient's demands and help patients carry out their rituals[111,123,135,138,139].

Types of accommodative behaviour

Accommodation encompasses a range of behaviours. Accommodation involves the direct participation of the family members in the patient's compulsive rituals to reduce the patient's and relatives' distress[24,134,135,140,141]. Family members also try to reduce distress by facilitating avoidance of situations that provoke the symptoms, providing reassurance, modifying family routines, or relieving the patients of their responsibilities to enable them to carry out compulsions[111,133,135,140,141].

Rates

Accommodation is widespread in families of patients with OCD. The reported rates range from over 90% for any instance of accommodative behaviour, while more frequent and severe accommodation is noted in about 60% of the families[111,134-136,142]. Family accommodation has been investigated more often among children and adolescents with OCD, but is equally likely to be present in families of adult patients[24,135,138,139,141].

Characteristics

Family accommodation may start as a well-intentioned attempt to help the patient reduce the distress due to obsessions. However, it is crucial to note that any anxiety relief is transient. The family reinforces the patient's behaviour by preventing them from learning from their experiences[111,134,136,137,140]. The consequent inability of patients to cope with symptoms and their dependence on relatives results in increased accommodation and symptoms. This sequence underscores the need for more effective interventions to break this "cycle of accommodation".

Correlates and consequences

The severity of OCD is the parameter most consistently associated with family accommodation[24,134-136,142]. More pertinently, several adverse outcomes, such as functional impairment in the patient, impaired family functioning, high caregiver burden and distress, impaired quality of life, and unfavourable course of OCD, are consistently associated with accommodation[24,133,135,140,141]. Accommodation is also associated with poor treatment response, resistance to CBT or ERP, and higher rates of dropout from treatment. These adverse outcomes underscore the urgent need to address family accommodation in the treatment of OCD.

MALADAPTIVE RESPONSES OF FAMILIES TO OCD: FAMILY ANTAGONISM

Definition

Unlike accommodation, antagonism occurs when family members refuse to yield to the patient's demands and are critical or hostile toward them[24,123,135,137,139]. Family antagonism is synonymous with high expressed emotions (EE). The high EE concept originated from research on schizophrenia. Later, it was extended to bipolar, depressive, and other psychiatric disorders[23].

Types of antagonism

High EE responses include criticism, hostility, or emotional over-involvement[22,23,137].

Rates

Like accommodation, studies of EE were first carried out among families of children and adolescents with OCD and later extended to the families of adult patients[23]. High EE is also very frequent among families of patients with OCD[22,23,137]. Parents of children and adolescents with OCD show 2-3 times higher rates of EE than parents of healthy children. High EE is present in 82% of such families compared to 41% in families of children and adolescents without OCD. In adults, high EE has been found in up to 75% of families of patients with OCD[23].

Characteristics

High EE families have higher rates of psychiatric disorders and more family and marital discord[137]. The presence of high EE in family members reduces the ability of the family to deal effectively with the problems posed by OCD. High EE relatives are more likely to consider obsessional symptoms to be a part of the patient's personality and believe that the patients can control their rituals[23,137].

Correlates and consequences

Patients belonging to high EE families have greater symptom severity and higher rates of distress, anxiety, and arousal, elevated rates of aggression, and more severe obsessional symptoms[22-24,135,137]. Patients belonging to high EE families have poor treatment responses, including poor responses to CBT or ERP[22-24,137,143]. A negative attributional style among relatives is associated with less benefit from ERP or CBT. More than overinvolvement, hostile criticism and perceived criticism appear to be associated with poor treatment outcomes[23,24,134]. Emotional overinvolvement and feelings of responsibility or guilt are associated with dropouts from CBT or ERP[137].

In summary, research over the past two decades has focused increased attention on inappropriate family responses to a person with OCD[22-24,135,137]. Family responses to OCD lie across a continuum from support and empathy to excessive compromise and overinvolvement, hostility, and rejection[137]. Two opposing kinds of inappropriate responses, accommodation and antagonism, have been noted among family members. Some families may have both responses in different members. Both accommodation and antagonism are associated with more severe OCD, several adverse patient and family outcomes, and poor response to CBT or ERP. Therefore, more effective psychotherapeutic interventions are needed to negate the adverse consequences of accommodation and antagonism.

FAMILY-BASED PSYCHOEDUCATION FOR OCD

Rationale

Clinicians and researchers felt the need for family-based psychoeducation for OCD because of the evidence that family accommodation and antagonism negatively influenced the course of OCD and the response to CBT or ERP[23,24,133].

Moreover, several studies showed that family-based psychoeducational treatment that targeted maladaptive family responses could reduce these responses and improve the outcome of OCD[23,24,135]. The reductions in family accommodation were associated with better treatment outcomes and improved patient and family functioning in OCD[24,133].

Lastly, despite the proven efficacy of CBT or ERP in OCD, a clinically significant response was seen in only about half of the patients with individual psychotherapy[134,142].

Family accommodation was one of the factors that contributed to suboptimal outcomes with individual CBT or ERP. Consequently, researchers developed family-based treatments focusing on reducing accommodation and antagonism for OCD[135,140,141].

Types of family-based psychoeducational treatments for OCD

Family-based psychoeducational treatments consist of the following components-involvement of patients and families or only families; psychoeducation about OCD and CBT or ERP for patients and families; incorporation of family members in CBT or ERP as coaches or co-therapists; techniques to reduce accommodation and antagonism; teaching problem-solving, illness-management, and communication skills; therapists acting as models for family members to learn these skills; and, the provision of emotional and practical support[22,111,123,135,144].

Table 9 shows the different models or formats of family-based psychoeducational treatments for OCD.

Table 9 Formats of family-based psychoeducational treatments for obsessive-compulsive disorder.

Format/model	Description
Family-assisted CBT or ERP	Family members are actively involved in providing CBT or ERP, family members act as coaches, co-therapists or supervisors of therapy[22,23]
Cognitive-behavioural family-based treatment (CBFT)	Includes all components of CBT or ERP, active involvement of family members in providing CBT or ERP, and training of family members in skills to reduce accommodation and antagonism[24,52,135]
Brief CBFT	Two sessions of psychoeducation and skills training in reducing accommodation for patients and family members[135,141]
Family-based CBT or ERP	Attended by both patients and family members. Family members provide CBT or ERP. Includes training of family members in reducing accommodation and antagonism[111,133,141]
Positive family interaction therapy	Adjunct to individual patient CBT. Teaches family members skills to handle accommodation and antagonism[111,140]
Family-integrated CBT or family-inclusive treatment	Family members join the patient in ERP or CBT and help the patient carry out the treatment. Family members receive treatment independent of the patient, individually or in groups. A combination of both approaches is used[24,139]
Couples-integrated CBT	Includes psychoeducation for patients and partners, couple-assisted ERP or CBT, couple-based interventions to reduce accommodation and antagonism, and couples therapy[115,141]
Parent training (SPACE-Supportive Parenting for Anxious Childhood Emotions program)	An intervention exclusively for parents of children with OCD. Children do not participate. Teaches parents to reduce accommodation, by identifying accommodative behaviours, learning skills to reduce such behaviours, and by providing support for parents[135,140,141,144]
Psychoeducational support groups	Psychoeducational support groups for family members only, or for patients and family members[23,24]
Multi-family treatments
Multi-family behavioural treatment	Combines elements of multi-family support groups, family-assisted CBT or ERP, and communication skills training[23,24]
Multi-family psychoeducational intervention	Psychoeducation and training in reducing accommodation and antagonism for groups of multiple families[23,135]

CBT: Cognitive behavioural therapy; ERP: Exposure and response prevention; OCD: Obsessive-compulsive disorder.

Efficacy of family-based psychoeducational treatments for OCD

Table 10 includes a selective review of the existing literature on the efficacy of family-based psychoeducational treatments for OCD[138,139,145-150].

Table 10 Efficacy of family-based psychoeducational treatments for obsessive-compulsive disorder.

Ref.	Type of evidence	Details	Findings
Thompson-Hollands et al[138]	Meta-analysis	29 studies of family-integrated treatment (FIT) for OCD	FIT reduced obsessional symptoms and improved patient functioning with large effect sizes. Individually-based FIT and FIT that focused on reducing accommodation were more effective than group treatments
Rosa-Alcázar et al[145]	Meta-analysis	33 studies of CBT for children with OCD	Moderate to high parental involvement in CBT improved the efficacy of CBT
Öst et al[146]	Meta-analysis	25 randomized trials of CBT in children and youth using the Children's Yale-Brown Obsessive Compulsive Scale	The degree of parental involvement or the family-based format of CBT did not affect the efficacy of CBT. A high degree of parental involvement was not a crucial factor for the success of CBT
Iniesta-Sepúlveda et al[147]	Meta-analysis	27 studies of cognitive-behavioural family-based treatment (CBFT) for children and adolescents with OCD	CBFT reduced obsessional symptoms with large effect sizes. CBFT had a moderate effect in reducing accommodation. Individually-based CBFT was more effective than group treatments
Guzick et al[148]	Meta-analysis	25 randomized controlled trials comparing standard CBT with augmented CBT in OCD	Increasing family involvement led to a better outcome of augmented CBT
McGrath and Abbott[149]	Meta-analysis	38 studies of family-based interventions for OCD in children and adolescents	Family-based interventions for OCD reduced obsessional symptoms and accommodation with large effect sizes. Interventions that targeted accommodation and other family factors were more effective
Stewart et al[139]	Meta-analysis	15 studies of FIT for OCD	FIT reduced symptoms of OCD, depression, anxiety, and improved patient functioning. Patient and family treatment satisfaction, antagonism, accommodation, and relatives’ mental health, and relationships also improved. Individually-based FIT and FIT that focused on reducing accommodation were more effective than group treatments. FIT was better than individual CBT. Fewer sessions were associated with better outcomes on certain parameters
Wang et al[150]	Meta-analysis	48 randomized controlled trials of ERP, CBT, CT, or third-wave CBT among children, adolescents and adults with OCD	Family-inclusive treatments had larger effect sizes than individual, group, or self-guided ERP or CBT

CT: Cognitive therapy; CBT: Cognitive behavioural therapy; OCD: Obsessive-compulsive disorder; ERP: Exposure and response prevention.

The efficacy of family-based psychoeducational treatments for OCD has been studied chiefly in families of children and adolescents[24,111].

However, two meta-analyses among families of adult patients with OCD found that family-integrated or family-inclusive CBT reduced OCD symptoms, attenuated family accommodation and antagonism, and improved family functioning[138,139]. Family-integrated treatments (FIT) also enhanced treatment satisfaction among patients and families, the family members' mental health, and family relationships[139]. FITs were better than individual CBT or ERP.

Other meta-analyses among children and adults have shown that increased family involvement improved the efficacy of CBT[145,148,150], but this was not a universal finding[146].

In conclusion, family-based psychoeducational treatments for OCD include family members in CBT or ERP and modify unhelpful family responses[24,138,139,146,148].

Figure 2 illustrates how family-based treatments act at various points in the "accommodation cycle" to improve the efficacy of CBT or ERP.

Figure 2 The “accommodation cycle” and the effect of family-based psychoeducational treatments. OCD: Obsessive-compulsive disorder; CBT: Cognitive-behavioural therapy.

The existing evidence shows that family-based psychoeducation for OCD is effective in reducing symptoms and maladaptive family responses and improving patient and family outcomes. However, there are methodological uncertainties in the research data.

THE EFFICACY OF PSYCHOEDUCATION FOR OCD: LIMITATIONS OF THE EVIDENCE

Psychoeducation as a stand-alone intervention for OCD

Table 8 shows that the number of trials of independent psychoeducational treatment is small. Moreover, their methodology was highly variable.

Most studies were open trials or retrospective reports. Only two trials were prospective controlled comparisons, but these trials did not randomly allocate patients. About half the trials used structured rating scales, principally the Yale-Brown Obsessive-Compulsive Rating Scale. These trials noted reductions in symptom scores and improvements in family functioning with psychoeducational treatment. Others used self-report scales or qualitative data, showing that psychoeducational treatment was feasible and acceptable. The number of patients in prospective trials ranged from 21 to 30.

The methodological inadequacies of the data do not support the efficacy of stand-alone psychoeducational interventions for OCD.

Results from studies of other anxiety disorders are more conclusive. In a meta-analysis of 12 studies of children and adolescents with anxiety disorders, Baourda et al[151] found that group psychoeducational treatment had a moderate effect on reducing anxiety symptoms. Therefore, independent psychoeducational interventions may have a role in the treatment of OCD that is currently unexplored[152].

Psychoeducation as a part of CBT or ERP for OCD

Many meta-analyses[150,153-156], systematic reviews[157,158], and studies show that ERP, or CBT, which includes ERP, is a proven treatment for OCD. However, there are methodological problems with the evidence.

The meta-analyses usually include a small number of studies[153]. There is considerable heterogeneity in findings across meta-analytic investigations[153,159]. There is a high risk of bias in most studies included in these meta-analyses[132,150,153-155].

This high risk of bias is due to problems in the individual studies. These include small sample sizes[13,132,153], non-experimental designs[153], variations in diagnostic and assessment procedures[150,153,158], and over-reliance on non-active waitlist controls[150,153].

The number of studies on the long-term efficacy of CBT or ERP is limited[13]. The moderators and predictors of treatment response are uncertain and inconsistent[13,153,159].

Finally, there is difficulty in applying the results of the meta-analyses to the entire population of patients because meta-analyses include randomised controlled trials with highly selective patient samples[132,154].

Although psychoeducation more commonly forms a part of CBT or ERP, the contribution of psychoeducation to the efficacy of CBT or ERP is unclear. The key components that contribute to the success of CBT or ERP are exposure sessions, cognitive strategies, psychoeducation, and stress management[119,132,145,160,161]. Some authors consider relapse prevention a crucial constituent, although the strategies for relapse prevention are not well-defined[132,145].

One approach to determining the active ingredients of multi-component psychotherapies, such as CBT or ERP, is to carry out dismantling studies[162]. Dismantling studies break up complex psychotherapies into individual components and compare them with the entire treatment protocol to determine the contribution of specific components to the overall treatment effect. Individual components are either excluded from the treatment or added in sequence to determine the contribution of each component. The current alternative to dismantling designs is network meta-analyses that can determine the efficacy of individual components[162].

In CBT or ERP for OCD, dismantling studies have shown that exposure sessions or ERP are the critical components of these treatments[130,160]. Network meta-analyses have shown no differences between the efficacies of cognitive therapy, CBT, and ERP[163]. However, the additional contribution of cognitive strategies is unclear[130,132,164]. Other dismantling studies and meta-analyses have examined the different types of exposure and found that a therapist-aided combination of live and imaginal exposure is more effective than other types[130,155,160].

Dismantling studies have rarely examined the contribution of psychoeducation to the efficacy of CBT or ERP for OCD[165]. Evidence from dismantling studies of panic control treatment for panic disorders shows that psychoeducation can independently reduce the frequency of panic attacks, while cognitive strategies decrease anxiety and cognitive errors[152].

Meta-analyses of CBT for anxiety and depressive disorders also provide clues to the independent efficacy of psychoeducation. A review of 30 such meta-analyses reported the strongest support for the efficacy of a collaborative alliance, a fundamental component of psychoeducation[166]. Two meta-analyses have shown that ERP is more efficacious than psychoeducational treatments in OCD[13,153], while several others have shown that ERP is more effective than stress management in OCD[11].

Therefore, there is a need for further studies to explore the contribution of psychoeducation to CBT or ERP for OCD.

Family-based psychoeducational treatments for OCD

Table 10 shows that family-based psychoeducation for OCD has a positive impact on several patient and family outcomes. However, the number of meta-analyses of family-based treatments is minimal compared to individual CBT or ERP.

There are other shortcomings. The meta-analyses that focused exclusively on family-based treatments consisted of randomised and non-randomised studies[138,139,147,149]. Others that examined the role of family involvement had inconsistent findings[145,146,148,150]. There was considerable heterogeneity in the findings of these meta-analyses of family-based psychoeducation, and the majority of studies included had a high risk of bias[138,139,147,149].

The moderator analyses showed that specific targeting of family accommodation processes improved the efficacy of family-based treatments[138,149]. Individually based family treatments were more effective than family groups[138,139,147]. Apart from these factors, there were very few consistent moderators of outcome.

Systematic reviews have also concluded that the evidence for family-based psychoeducation for OCD is preliminary, small in size, and many studies are methodologically inadequate[133,140,141].

CHALLENGES IN DELIVERING PSYCHOEDUCATION FOR OCD

Improving access to psychoeducational treatments for OCD

Low rates of treatment-seeking, lack of access to CBT, and long delays in help-seeking characterise the treatment of OCD worldwide[4,5,14]. Psychoeducation can help improve help-seeking and promote early intervention[17]. However, several patient-related, provider-related, and organisational factors hinder access to treatment. Implementation of psychoeducational treatments in routine settings is also challenging[116].

Training clinicians in the detection and treatment of OCD, increasing resources for specialist treatment, and using digitally-based interventions can surmount many obstacles to disseminating psychoeducational treatments[165,167].

Digital interventions can be particularly useful in increasing access to specialist treatment[116,158,165,167,168]. Digital CBT is as effective as in-person CBT for OCD.

Moreover, digital interventions can overcome many of the limitations of conventional CBT or ERP, such as inadequate access from distant areas, transportation, and travel difficulties, the stigma of having to attend a mental-health facility, and difficulties with in-person attendance for working people, the elderly with poor mobility, or young mothers with childcare responsibilities. Digital CBT or ERP saves costs and travel time, can prevent treatment delays, is more convenient for patients and clinicians, and may improve motivation and treatment engagement because of frequent clinician contact.

Cultural adaptation of psychoeducational treatments

Research on the treatment of OCD from low- and middle-income countries is scarce[14,169]. There is also a lack of effort to develop culturally adapted treatments in these countries[170].

Adaptation is required when there is poor acceptability and treatment engagement, sociocultural differences in the disorder and its treatment, and when the original treatment proves ineffective in the new setting[171-173]. Adaptation aims to improve adherence to the adapted treatment and engagement with the treatment services, and ensure that the adapted treatment produces satisfactory clinical outcomes to change the targeted measures.

Culturally adapted treatments for OCD have better outcomes than those that are not adapted[33,170]. Nevertheless, studies of CBT or ERP for OCD have been mainly conducted in Western countries among White, middle-class subjects attending specialist clinics[116,174,175]. The evidence supporting the efficacy of culturally adapted CBT or ERP for OCD in ethnic minorities and from non-Western countries is scarce and preliminary. The lack of research is unfortunate, given that cultural attitudes and beliefs influence help-seeking and the outcome of treatment[174,175].

However, more recently, there have been encouraging efforts from non-Western countries to develop culturally adapted CBT or ERP that is effective in treating OCD. These studies of CBT, ERP, or family-based psychoeducation have been conducted in Japan[175], China[176], Korea[177], Brazil[178], and the Middle East[179].

CONCLUSION

Psychoeducation is a structured but straightforward treatment with well-defined goals and principles. Psychoeducation as an independent treatment has proven efficacy in schizophrenia and bipolar disorder, but not OCD. Although psychoeducation is integral to ERP or CBT for OCD, research on the efficacy of psychoeducation is relatively limited in OCD. The new set of family-based psychoeducational treatments developed to address inappropriate family responses to OCD has proved to be better than individual psychoeducation in reducing obsessional symptoms, attenuating family accommodation, and improving family functioning. Family-based psychoeducation is a promising treatment for OCD. However, optimising psychoeducational treatments for OCD and efficiently delivering these treatments in routine clinical settings, particularly the resource-constrained settings of low- and middle-income countries, will require further effort.