The Theory and Practice of Group Psychotherapy (99 page)

And do not forget the psychological stigma attached to many medical illnesses, for example, HIV/AIDS, irritable bowel syndrome, and Parkinson’s. At a time when individuals are in great need of social support, the shame and stigma of illness can cause social withdrawal and stress-inducing isolation.

Additionally, seriously ill individuals and their families fear uttering anything that might amplify worry or fear in loved ones. The press for “thinking positive” invites shallowness in communication, which further increases a sense of isolation.
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More than ever before, we are aware of the psychological importance of patient-doctor communication in chronic medical disease. Collaborative, trusting communication between patient and doctor is generally associated with greater well-being and better decision making.
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Yet many patients, dissatisfied with their relationship with their physician, feel powerless to improve it.

Medical illness confronts us with our fundamental vulnerability and limits. Illusions that have sustained us and offered comfort are challenged. We lose, for example, the sense that life is under our control, that we are special, immune to natural law, that we have unlimited time, energy, and choice. Serious illness evokes fundamental questions about the meaning of life, death, transiency, responsibility, and our place in the universe.
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And, of course, the strain of medical illness extends far beyond the person with the illness. Family members and caregivers may suffer significant stress and dysphoria.
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Groups often play an important role in their support: for example, consider the enormous growth in groups for caretakers of patients with Alzheimer’s disease.
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General Characteristics

Typically, groups for the medically ill are homogeneous for the illness and time-limited, meeting four to sixteen times. Groups that help patients with coping and adaptation
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may be offered at every step of the individual’s illness and medical treatment.

As I discussed in chapter 10, brief groups require clear structure and high levels of focused therapist activity. But even in brief, highly structured, manual-guided group interventions, the group leader must attend to group dynamics and group process, not necessarily to explore them, but to manage them effectively so that the group does not get derailed and become counterproductive.
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Although homogeneous groups tend to jell quickly, the leader must be careful to bring in outliers who resist group involvement. Certain behaviors may need to be tactfully and empathically reframed into a more workable fashion. Consider, for example, the bombastic, hostile man in a post–myocardial infarction ten-session group who angrily complains about the lack of concern and affection he feels from his sons. Since deep interpersonal work is not part of the group contract, the therapist needs to have constructive methods of addressing the patient’s concerns without violating the groups norms. In general, therapists would seek to contain, rather than amplify the client’s distress, or have it generate a charged negative emotional climate in the group. They might, for example, take a psychoeducational stance and discuss how anger and hostility are noxious to one’s cardiac health, or they might address the latent hurt, fear or sadness that the anger masks, and invite a more direct expression of those primary emotions.

Although these groups do not emphasize interpersonal learning (in fact, the leader generally avoids here-and-now focus), many of the other therapeutic factors are particularly potent in group therapy with the medically ill.
Universality
is highly evident and serves to diminish stigmatization and isolation.
Cohesiveness
provides social support directly. Extragroup contact is often encouraged and viewed as a successful outcome, not as resistance to the work of the group. Seeing others cope effectively with a shared illness
instills hope,
which can take many forms: hope for a cure, for courage, for dignity, for comfort, for companionship, or for peace of mind. Generally, members learn coping skills more effectively from the
modeling
of peers than from experts.
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Imparting of information
(psychoeducation—in particular about one’s illness and in general about health-related matters) plays a major role in these groups and comes not only from the leaders but from the exchange of information and advice between members.
Altruism
is strongly evident and contributes to well-being through one’s sense of usefulness to others.
Existential factors
are also prominent, as the group supports its members in confronting the fundamental anxieties of life that we conceal from ourselves until we are forcibly confronted with their presence.†

Clinical Illustration

In this section I describe the formation, the structure, and the usefulness of a specific therapy group for the medically ill: a group for women with breast cancer.

The Clinical Situation.
At the time of the first experimental therapy groups for breast cancer patients, in the mid-1970s, women with breast cancer were in serious peril. Surgery was severely deforming and chemotherapy poorly developed. Women whose disease had metastasized had little hope for survival, were often in great pain, and felt abandoned and isolated. They were reluctant to discuss their despair with their family and friends lest they bring them down into despair as well. Moreover, friends and family avoided them, not knowing how best to speak to them. All this resulted in a bidirectional and ever-increasing isolation.

Breast cancer patients felt hopeless and powerless: they often felt uncared for and unheard by their physicians but unable to complain or to seek help elsewhere. Often they felt guilty: the pop psychology of the day promulgated the belief that they were in some manner responsible for their own disease.

Finally, there was considerable resistance in the medical field to forming a group because of the widespread belief that talking openly about cancer and hearing several women share their pain and fears would only make things worse.
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Goals for the Therapy Group.
The primary goal was reduction of isolation. My colleagues and I hoped that if we could bring together several individuals facing the same illness and encourage them to share their experiences and feelings, we could create a supportive social network, destigmatize the illness, and help the members share resources and coping strategies. Many of the patients’ closest friends had dropped away, and we committed ourselves to continued presence: to stay with them—to the death if necessary.

Modification of Group Therapy Technique.
After some experimentation with groups of patients with different types and stages of cancer, we concluded that a homogeneous group offered the most support: we formed a group of women with metastatic breast cancer that met weekly for ninety minutes. It was an open group with new women joining the group, cognizant that others before them had died from the illness.

Support was the most important guiding principle. We wanted each member to experience “presence”—to know others facing the same situation. As one member put it, “I know I’m all alone in my little boat, but when I look and see the lights on in all the other boats in the harbor, I don’t feel so alone.”

In order to increase the members’ sense of personal control, the therapists turned over as much as possible of the direction of the group to the members. They invited members to speak, to share their experiences, to express the many dark feelings they could not discuss elsewhere. They modeled empathy, attempted to clarify confused feelings, and sought to mobilize the resources available in the membership. For example, if members described their fear of their physicians and their inability to ask their oncologist questions, the leaders encouraged other members to share the ways they had dealt with their physicians. At times the leaders suggested that a member role-play a meeting with her oncologist. Not infrequently a member invited another group member to accompany her to her medical appointment. One of the most powerful interventions the women learned was to respond to a rushed appointment with a doctor with the compellingly simple and effective statement, “I know that you are rushed, but if you can give me five more minutes of your time today, it may give me a month’s peace of mind.”

The leaders found that expression of affect, whatever it might be, was a positive experience—the members had too few opportunities elsewhere to express their feelings. They talked about everything: all their macabre thoughts, their fear of death and oblivion, the sense of meaninglessness, the dilemma of what to tell their children, how to plan their funeral. Such discussions served to detoxify some of these fearsome issues.

The therapists were always supportive, never confrontational. The here-and-now, if used at all, always focused on positive feelings between members. Members differed greatly in their coping styles. Some members, for example, wanted to know everything about their illness, others preferred not to inquire too deeply. Leaders never challenged behavior that offered comfort, mindful never to tamper with a group member’s coping style unless they had something far superior to offer. Some groups formed cohesion-building rituals such as a few minutes of hand-holding meditation at the end of meetings.

The members were encouraged to have extragroup contacts: phone calls, luncheons, and the like, and even occasional suicide phone vigils, were part of the ongoing process. Some members delivered eulogies at the funerals of members, fulfilling their pledge never to abandon one another.

Many members had overcome panic and despair and found something positive emanating from the confrontation with death. Some spoke of entering a golden period in which they prized and valued life more vividly. Some reprioritized their life activities and stopped doing the things they did not wish to do. Instead they turned their attention to the things that mattered most: loving exchanges with family, the beauty of the passing seasons, discovering creative parts of themselves. One patient noted wisely, “Cancer cures psychoneurosis.” The petty things that used to agonize her no longer mattered. More than one patient said she had become wiser but that it was a pity she had to wait until her body was riddled with cancer before learning how to live. How much she wished her children could learn these lessons while they were healthy. These attitudes resulted in their welcoming rather than resenting student observers. Having learned something valuable from their encounter with death, they could imbue the final part of life with meaning by passing their wisdom on to others, to students and to children.

Leading such a group is emotionally moving and highly demanding. Co-therapy and supervision are highly recommended. Leaders cannot remain distant and objective: the issues addressed touched leaders as well as members. When it comes to the human condition, there is no “us and them.” We are all fellow travelers or fellow sufferers facing the same existential threats.
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This particular group approach, which is now identified as supportive-expressive group therapy (SEGT), has been described in a series of publications
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and been taught to a range of psycho-oncology professionals.
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SEGT has also been used for related conditions: for women with primary breast cancer, a disease that carries a good prognosis for the vast majority of women, as well as for women with a strong genetic or familial predisposition to develop breast cancer. Reports describe effective homogeneous groups that meet for a course of twelve weekly sessions. The last four meetings may be used as boosters, meeting once monthly for four months, which extends exposure to the intervention for six months. In these groups, one’s own death may not be a primary focus, but coping with life’s uncertainty, prophylactic mastectomy, and shattered illusions of invulnerability are central concerns. Grief and loss issues related to mothers and family members who may have died of breast cancer are also prominent.
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Effectiveness.
Outcome research over the past fifteen years has demonstrated the effectiveness of these groups. SEGT for women at risk of breast cancer, women with primary breast cancer, and women with metastatic disease has been shown to reduce pain, and improve psychological coping. The medical profession’s apprehension that talking about death and dying would make women feel worse or cause them to withdraw from the group has also been disconfirmed.
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Can groups for cancer patients increase survival time?
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The first controlled study of groups for women with metastatic breast cancer reported longer survival, but several other studies, have failed to replicate those findings. All of the studies, however, show significant positive psychological results: although the group intervention most likely is not life prolonging, there is little doubt that it can be life altering.
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ADAPTATION OF CBT AND IPT TO GROUP THERAPY

It can be valuable indeed to use a pluralistic approach to psychotherapy—that is, to integrate into one’s approach helpful aspects of other approaches to therapy. In this section I explore two widely used current models of group therapy in order to identify methods that all therapists can effectively incorporate into their work (a far more constructive stance than to assume a competitive approach that narrows our therapeutic vision).