The art of group therapy tokyo 2

Each type of group = effective• During the last 20 years, each type of support group has shown significant effectiveness in helping patients improve their mood, learn new ways of copi

THE ART OF GROUP THERAPY

Kanagawa Cancer Center

October 21, 2010

Patricia Fobair, LCSW, MPH

Stanford University Medical Center

Supportive Care Program

fobair@sbcglobal.net

The Art of Leading Support Groups

by Pat Fobair, LCSW, MPH

• History of group support in

America • Types of Groups?

• What are we hoping to achieve in groups?

• How do groups help? Therapeutic factors?

• What are the tasks in group leadership?

• Treatment strategies?

• Teach active coping—

• How do you know when patients have found benefit

from the group?

History of Group Therapy in America

Social Group work began with Jane Addams at Hull House in Chicago in response to European immigration in the 1890’s Hospital group work began with Ida Cannon at Massachusetts General Hospital in the early 1900’s, a response to

Tuberculosis patients’ need for education and

Types of Groups Research on Group Effectiveness

• Open Ended Groups, drop in groups,

Woods, 1978; Lonergan, 1985; Yalom, 1983

• Education Groups “I can cope,”

Johnson, 1982; Jacobs, 1983;

• Cognitive-Behavioral Weisman, Worden, Sokel, 1980; Telch and Telch, 1986; Fawzy & Fawzy, 1993

• Self-Help —Cella, 1993; Toro et al , 1987

• Supportive-Expressive —Spiegel et al., 1981, 1989, 1991

Each type of group = effective

• During the last 20 years, each type of support

group has shown significant effectiveness in

helping patients improve their mood, learn new

ways of coping, offering members opportunity to express their feelings.

• A recent study confirms this observation:

Bell, K., Lee, J., Foran, S., Kwong, S., & Christopherson, J (2010) Is there an "Ideal Cancer" Support Group? Key

Findings from a Qualitative Study of Three Groups Journal

of Psychosocial Oncology, 28(4), 432-449

• In the 1970’s David

Spiegel began leading

groups with Irvin Yalom with metastatic breast cancer patients In 1990, David received a large grant to explore whether groups could help

patients survive longer.

• Pat Fobair joined

David’s work in 1990.

Why do patients need a group?

-Attitude makes a difference!

• “Hopelessness” and “Depression” predicted mortality among breast

cancer patients.

Watson et al (1999) Lancet

• Lack of distraction” and “Fighting spirit” predicted longer survival with

adult leukemia patients.

Tschuschke et al (2001) J Psychosom Res.

• There were significant declines in total mood disturbance and traumatic stress symptoms for the patients in the treatment condition compared with controls.

Classen et al (2001) Archives of General Psychiatry

• Lack of avoidance and realistic optimism are key goals of support

groups

Spiegel (2001) J Psychosom Res

What are you hoping to achieve with

group supports?

• Purpose: Provide emotional and social

support for participants:

• Goals: 1) Reduce stress;

• 2) Offer a safe place where medical decision making issues can be discussed;

• 3) Encourage expression of emotions;

• 4) Encourage active coping.

Group Therapy Reduces Stress

• “Supportive-Expressive Group Therapy and

Distress in Patients With Metastatic Breast

Cancer: A Randomized Clinical Intervention Trial”

• In a study of 125 women with metastatic breast

cancer (64 intervention, 61control group),

• Results found a greater decline in traumatic stress symptoms on the Impact of Event Scale (effect

size, 0.25) Catherine Classen, et al 2001 Archives of General Psychiatry, ( 58, May 2001, 494-501)

How Groups Help in Coping with

Acute Stress

• By “normalizing” the reactions.

• By creating a safe environment to express strong feelings.

• By helping group members discover the

personal meaning in the experience

– Classen, Koopman, Hales, and Spiegel, 1998

Therapeutic Factors in Groups

Irvin Yalom

• Universality removes one’s sense of isolation

with a problem,

• Altruism group members help each other,

• Instillation of hope group members inspired by

those who have overcome problems,

• New Information learning factual information from

other members, helps,

• Development of socializing techniques.

• Corrective family re-enactment

Therapeutic Factors in Groups 2

• Imitative behavior developing social skills by

imitating therapist and group members,

• Cohesiveness all members feel a sense of

belonging, acceptance, and validation,

• Existential factors taking responsibility for one’s

life & results of decision making,

• Catharsis experiencing relief from emotional

distress through expression of emotion,

• Interpersonal learning, and Self Understanding

Common Themes in Cancer Groups

• Patients’ distress and trauma in

learning about cancer diagnosis;

• Their fears of recurrent disease;

• Their sense of damage to their body;

• Their fear of loosing self-sufficiency

and control in life

Yalom and Spiegel suggest that Supportive-Expressive groups help in

Expressing emotion is therapeutic

because, it helps people

to • Face fears directly,

• Distinguish problems from people

“People are not the problem, people have problems.” Robert Watts, PhD

• Expressing emotions brings us closer to each other We feel less isolated.

Treatment Strategies

• Teaching Active Coping

Coping with loss of control

• When you are feeling “out of control”

(anxious) recall recent thoughts and feelings which disturbed you.

• The stress of ‘feeling blamed’ or ‘not being chosen,’ or ‘recognized’ bring up negative

feelings.’

• Your distress may remind you of other

disappointments you’ve had earlier in life

Regain inner control

by-1) identifying feelings, (anxious) name your fear.

2) Allow yourself to acknowledge that you are

‘annoyed’ or ‘hurt;’ ‘honor your experience.’

3) Now, imagine what you might do to change the

outcome of the problem.

4) Imagine several constructive ideas.

5) Choose one step you can take towards solving the problem, and commit to taking the step.

6) Remember, “we are not helpless, only small

children are helpless.”

themselves to each other,

3) Support the group members as they address the

issues and feelings expressed,

4) Before meeting ends, ask “as we come to close

are their any final questions or comments?”

Tasks of the Group Leader

• Set limits of group member’s behavior, by 1) Starting & stopping the group on time,

2) Do not encourage ‘advice’ giving,

3) Do not allow, ‘scapegoating’ of an

unpopular group member,

4) Offer support to group members when they

are being misunderstood by other group

members.

Self-Esteem Reparation Technique

• Support the individuality of group members Patients are more than sick people.

• Underline the commonality patients have

with others Grasping our similarity with

others is a curative factor in groups.

• Encourage group member helpfulness to

each other.

• Emphasize individual strengths.

» Lonergan, 1985; Yalom, 1970

Remember these useful ideas from

Existentialism

• “Consciousness is a source of freedom.”

• Anxiety over trying new things, is a normal part of our experience with freedom.

• We can say “no” to situations in which we

find ourselves.

• We can ‘downplay’ negative feelings.

• We can look at situations in terms of how we might change them Jean-Paul Sartre, 1956

Self conscious emotions and depression

• Ongoing shame or unresolved guilt may be

associated with chronic depression, trauma

symptoms, sexual disruption, and may impact

physiology.

Tangney, Fischer (eds) Self-Conscious Emotions: The Psychology of Shame,

Guilt etc New York: the Guilford Press (1995)

• Shame or unresolved guilt may impede recovery

among breast cancer patients.

• Sexual embarrassment predicts sexual morbidity in

breast cancer recovery

Giese-Davis & Spiegel (2003) Research funded by California Cancer Research

Group Treatment

offers 1 Social Support ‘Similar others’ provide an important social connection

2 Emotional Expression Helps reduce social isolation and leads to improved coping.

3 Detoxifying Problems: Processing Existential

concerns, like cancer, death, freedom, isolation, and meaninglessness By meeting these problems head

on group members use their time better

Spiegel, (2002) Encyclopedia of Psychotherapy

Description of Treatment

4 Reorganizee Life Priorities and Live in the Present

Patients take control of the life they have left.

5 Enhance Family Support Improve communication,

identify needs, increase role flexibility, and adjust to new medical, social, vocational, and financial realities.

6 Improve Communication with Physicians

7 Symptom Control Problem focused coping

Spiegel, (2002) Encyclopedia of Psychotherapy

Leadership Values

• Our biological existence is

primary-• Therapists take a nonjudgmental

attitude-• Act as role models of openness sharing

more of themselves-

• Encourage themes where group members discuss mortality issues, freedom, isolation and the meaning in life

(Existentialist viewpoint)

Leadership Values

• The social world is more than a tangible,

objective system -we are connected.

• Social reality is a matter of the way we conceive

and define it cultural relevance.

• We create our own culture as we interact with

each other in groups

• When retelling stories group members give

meaning to the intrusiveness of illness

» (Post modernist viewpoint)

Highest Values Appreciated in World

Other qualities of leadership

1 A good leader encourages the trust of others

2 A good leader is enthusiastic about their work

3 A good leader is confident about the process

4 A leader functions in a purposeful manner in situations of uncertainty

5 Good leaders tolerant ambiguity and remain calm,

composed and steadfast to group’s purpose.

6 A good leader thinks analytically, sees the group as a whole, and imagines the sub-parts that lead to the goal

.

Each type of group requires different

Treatment Strategies

• Educational groups are highly structured Each meeting is organized around a theme Reading and homework add continuity

• Cognitive-behavioral groups teach patients

to examine their thoughts & beliefs & notice how they play out in personal behaviors

Problem solving is encouraged.

• Supportive-Expressive groups encourage personal disclosure and story telling.

Helpful Therapist Behaviors

• Positive Affect: Accepting, Affection, Validation,

Interest and Humor.

• Evocative: Inviting, Eliciting, Questioning, Reflecting

• Support: Appreciates Members Problems.

• Cognitive: Interpret, Contrast, Reframe Problems

• Management: Time, Focusing, Goals

• Use of Self: Reveals Own Feelings, Beliefs.

Leadership Tasks in Starting a Group

• Overall Group purpose: Help group members to cope with all

aspects of the cancer experience.

• Introductions: Inviting each to describe themselves, and

cancer experience.

• As personal difficulties emerge, offer supportive comments,

invite group members to respond briefly

• The Problems mentioned by patients become your agenda.

• Try to address each problem in same session.

Leadership Tasks-Process Issues

Assume function of leadership-by 1) Being intuitively active, demonstrate receptive

capacity to pick up patients’ verbal and

emotional expression.

2) Working through by sharing and naming what

is going on.

Brock, 2001

Leadership

Tasks-• Be aware of group members’ anxieties.

• Recognize there are many feelings in the room.

• Enable the circulation of feelings within your group

• Example: “How is this feeling to us now?”

Brock, 2001

Look for Emotions among the Group

Members

1 Signs of visible emotion-anxiety, tears.

2 Possible death of a loved one.

3 Difficulties in caring for a loved one.

4 Communication problems within families.

5 Discomfort or tensions among group members.

6 Tension within group with leadership.

» Spiegel and Classen, 2000

Dealing with Dying

• Dealing with one’s potential death is an

opportunity for group members talk about their feelings of -

1 Isolation, and the need to stay connected.

2 Freedom, seeing the choices available.

3 Meaning, using life to help others cope.

» Spiegel and Classen, 2000, Yalom, 1980

Group Process-Fraternal Stage

• “We-ness” is happening when

1) group members become inclined to put

themselves at risk, emotionally, 2) they no longer turn only to the leader,

3) they locate their personal thoughts

within the group

Leadership Tasks-Discover the

“Genius Loci”

• One group member will become the “Genius

Loci,” the person willing to be vulnerable in

emotional expression

• The “Genius Loci,” is someone who works side

by side with the therapist while remaining a

patient group member.

» Brock, 2001

“Twinship” and “Similar Others”

• There is a human need to find others who have had

experiences like ours.

• Finding our ‘difficult time’ reflected in the stories of

others adds vitality, mutual affirmation and pleasure to those involved (Gorney, 1995).

• Study participants who talked often with “similar others,”

experienced improvements in their physical and

emotional well-being over time (Thoits, et al, 2000).

Leadership Tasks-Community

• Group leaders create a sense of community where moments of ‘sameness,’ can be

discovered by group members,

by 1) Empathy: our verbal and nonverbal

understanding, that we know what they are experiencing.

2) Reframing the patient’s story, providing a

fresh more positive way of looking at the situation.

Treatment Strategies

• Encourage group members to express

their thoughts and emotions

• When we lose our sense of inner control

there is a desire to avoid or deny how

threatened we feel.

• Yet, we gain more control over negative

feelings as we express them to others.

• -“Something in me needed to hear stories

of survival from people who are coping with

it daily.” (Tim Batchelder, 1998)

Expressing Feelings

• Sharing feelings can feel like letting go of

‘secrets.’

• Once expressed, fear subsides Feelings

lead to new possibilities.

• Example, “It was very important for me to

give voice to a confession that I truly wanted

to live and to be healed I had been afraid

that I might die.” (William Ahlem, Jr 1999)

Treatment Strategies

Maintain the Focus on Cancer

• Explore Spontaneous Digressions, they may lead to personal discovery, then-

• Redirect Discussion, back to cancer.

• Explore Emotions as they come up.

• Emotions reflect our consciousness, a center, where our inner lives meet the outside world.

Hidden problems require sensitive group

leadership

• Ongoing shame or unresolved guilt may be

associated with chronic depression, trauma

symptoms, sexual disruption, and may impact

physiology.

Tangney, Fischer (eds) Self-Conscious Emotions: The Psychology of Shame,

Guilt etc New York: the Guilford Press (1995)

• Shame or unresolved guilt may impede recovery

among breast cancer patients.

• Sexual embarrassment predicts sexual morbidity in

breast cancer recovery

Giese-Davis & Spiegel (2003) Research funded by California Cancer Research

Help patients talk about ‘hidden’

problems when they come up in group

• Most ‘hidden’ problems of shame or guilt

have been experienced by others.

• You can ask the group members as a whole,

“ Have any of you experienced something

like Mika is telling us?”

• Encourage others to tell their ‘similar’

stories, this relieves the tension in group.

• If no one volunteers, I tell a story about

myself that relates the patient’s shame.