The art of group therapy tokyo 2

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 groups help? Therapeutic factors? What are the tasks in group leadership? Treatment strategies? Teach active coping— How 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 companionship in difficulty After World War II, many forms of groups began to flourish in medical and psychiatric hospitals Yalom and Spiegel’s work began in the 1970’s at Stanford; Pat Fobair began leading groups in 1970 at Mount Zion Hospital in San Francisco 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 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 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 The art of group therapy in redirecting a negative experience in the room • The patient who moralizes, competes, is help-rejecting, a complainer, or silent is -feeling defensive about something that’s making them feel ‘out of control.’ • Ask them, “Tell me more about your thoughts and feelings, right now.” There is something they need to say, but feel they cannot express Help them talk directly about the problems they face within themselves Coping with ‘Scapegoating’ • When one group member blames another for something, they are usually projecting the most disliked aspect of himself, herself • Leader asks the scapegoated group member, “How was that for you to hear what was just said?” • Turning to the speaker & group, the leader asks, “What are your feelings about what you’ve just heard?” Allow time for discussion • Leader ends by reframing the attack as a worry or unexamined turf issue that reflects a difference in opinion or priorities Handling Group Problems • Group leaders defuse tensions in the room 1) by helping both sides express their feelings • 2) by ‘reframing’ the problem, using different wording and • 3) by explaining it as a misunderstanding, difference of opinion, a priority difference, or a difference in values Treatment Strategies • Facilitate supportive interaction among group members by: 1) Encouraging group members to comment on their experience with another's problem 2) Connecting similarities between group member experience 3) Staying ‘out of the way’ when helpful interactions spontaneously occur Treatment Strategies • Work in the ‘here and now.’ This is the active ingredient in group process Yalom, (1985) • Bring alive the process in the room: 1) Activation: “How is this feeling for you, now, in the group?” (normalizing) 2) Illumination: “How did it feel to you when Jenny told you how your story affected her?” (less isolated) Encouraging Emotional Expression • Acknowledge feelings as they come up“Oh, that must have been tough for you!” • ”How was that for you? Can you say more?” • Identify the emotion-”How did that feel?” “How did others feel, when Laura told us the story?” “What did that bring up for us?” • Find understanding in group and therapist for patients situation and feelings Teach Active Coping • Anticipate What’s Coming- Plan for tomorrow • Communicate Concerns-”I’m scared.” • Problem Solve, Gather information, choose best option • Relax, Sooth Yourself, Pray.• Check out Your Beliefs,- ”Life isn’t fair.” • Give Yourself Permission to Feel your Feelings, Anger, Fear, and Disappointment - • Choose to Accept what you cannot change and Forgive those who have hurt you.- “It’s therapeutic.” You are teaching patients that they can• Recognize their need for support• Ask for what they want• Reach out to family and friends• Include others in their circle• Improve their doctor-patient relationship- & • Accept and forgive the failure of others- Patients are on the road to healing when: • They find themselves using spontaneous humor, or story telling in conversations • They called someone to say they were sorry • They reached out to people they like and planned activities • They shared a secret thought or feeling with someone, maybe someone in the group Pat Fobair My thanks to you, I’ve enjoyed being with you today,—Pat Fobair [...]... to each other, Support the group members as they address the issues and feelings expressed, Before meeting ends, ask “as we come to close are their any final questions or comments?” Tasks of the Group Leader • 1) 2) 3) 4) Set limits of group member’s behavior, by Starting & stopping the group on time, Do not encourage ‘advice’ giving, Do not allow, ‘scapegoating’ of an unpopular group member, Offer support... 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.” Tasks of Leadership • 1) 2) 3) 4) Creating the group s ‘atmosphere’ during 1 st meeting Introduce yourself, and purpose of the meeting, Invite other group members to introduce themselves... member, 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... Existential concerns, like cancer, death, freedom, isolation, and meaninglessness By meeting these problems head on group members use their time better Spiegel, (20 02) 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... Problem focused coping Spiegel, (20 02) 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... 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... 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 20 01 Archives of General Psychiatry, ( 58, May 20 01, 494-501) How Groups Help in Coping with Acute Stress • By “normalizing” the reactions • By creating a...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... 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... 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-• • • • • ... 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 groups help? Therapeutic... Tasks of Leadership • 1) 2) 3) 4) Creating the group s ‘atmosphere’ during st meeting Introduce yourself, and purpose of the meeting, Invite other group members to introduce themselves to each other,... limits of group member’s behavior, by Starting & stopping the group on time, Do not encourage ‘advice’ giving, Do not allow, ‘scapegoating’ of an unpopular group member, Offer support to group