Effects of Group Therapy for people with Cancer Patricia Fobair, LCSW, MPH Supportive Care Program, Stanford University Hospital, Cancer Program Overview of Effects of Groups Positive effects—improves mood and knowledge; lowers stress, anxiety, depression, less vomiting and pain Neutral effects -less needy patients experience less of benefit Negative effects -a small percentage of patients find groups not helpful Effectiveness studies   Meta-analysis of 116 studies found positive benefits for adults with cancer: less anxiety, depression, nausea; better mood and patient knowledge Devine, E C., & Westlake, S K (1995) Oncology Nursing Forum, 22, , 1369-1381 One of the earliest randomized studies to show a positive outcome of improved mood, “Group support for patients with metastatic cancer Spiegel, D., Bloom, J R., & Yalom, I (1981) Arch Gen Psychiatry, 38(5), 527-533 Recent studies of effectiveness  Psychosocial interventions as part of breast cancer rehabilitation programs? Results from a systematic review Fors EA, Bertheussen GF, Thune I, Juvet LK, Elvsaas IK, Oldervoll L, Anker G, Falkmer U, Lundgren Psychooncology 2010 Sep [Epub ahead of print] Results of this study: In out of studies of cognitive behavioral therapy, the Quality of life improved when patients were provided group therapy immediately after primary breast cancer treatment S, Leivseth G  Group Support found helpful   In the San Francisco Bay area, Levine and her group (2005) assigned 181 breast cancer patients to support group or to complementary/alternative intervention Results: 91% of the support group and 80% of the complementary/alternative intervention improved symptoms of stress; support group showed greater decrease in overall stress  Levine, E G., Eckhardt, J., & Targ, E (2005) Change in posttraumatic stress symptoms following psychosocial treatment for breast cancer Psycho-Oncology, 14(8), 618-635 Three controlled studies from Japan In a study by Fukui, Kugaya, Okamura et al (2000)  -50 breast cancer patients were randomized into a week structured, (25) group intervention or (25) control The class topics included health education, coping skills training, stress management and psychological support  Fukui et al (2000) found that the patients in the experimental group had significantly lower scores than controls for total mood disturbance, along with a higher score of vigor - Cancer, 89(5), 1026-1036 Three controlled studies from Japan Fukui, Koike, Ooba, & Uchitomi (2003) In a secondary analysis Fukui et al looked at loneliness, number of confidants, and satisfaction with confidants and mutual support The experimental group had significantly lower loneliness scores than the control patients, and significantly higher scores for the number of confidants, as well as greater satisfaction with confidants, and with mutual support over the six-month study period Oncology Nursing Forum, 30(5), 823830 Three controlled studies from Japan Maeda, Kurihara, Morishima, & Munakata (2008) studied the effectiveness of psychological intervention on personality change, enhancing perceived emotional support, adaptive coping and psychological well-being of 28 primary breast cancer patients (14 experimental, 14 control group) The intervention consisted of sessions that included providing medical and psychological information and counseling using structured association techniques; 3-4 days after surgery, months later post intervention and months follow-up Intervention seemed to enhance the short-term personality change, adaptive coping, and psychological well-being of experimental patients More studies are needed to confirm Cancer Nursing, 31(4), E27-35 Groups at Stanford University Stanford study finds improvement    Classen, C., Butler, L D., Koopman, C., Miller, E., DiMiceli, S., Giese-Davis, J., et al (2001) Supportiveexpressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial Arch Gen Psychiatry, 58(5), 494-501 125 breast cancer patients with metastatic disease were studied 64 intervention group with a year group intervention, versus 61 controls Group members showed a decline in IES trauma (stress) Benefits of psychosocial oncology care: Improved quality of life    “Interventions to treat distress and improve quality of life in cancer patients are widely available, effective, and standardized.” “Given the bulk of literature available detailing the efficacy of various types of interventions for patients at all points of the illness trajectory,-It would seem ill considered not to provide these services to cancer patients.” Carlson, L E., & Bultz, B D (2003) Health and Quality of Life Outcomes, 1(8), 1-8 Neutral Effects  The patients who benefit most from groups tend to be those who are most distressed  Vos et al 2004, 2007, found that when comparing patients without high distress in support groups, versus patients held in control, that well-adjusted women diagnosed with breast cancer did not specifically benefit from group interventions  Vos, P J., Garssen, B., Visser, A P., Duivenvoorden, H J., & de Haes, H C (2004) Psychotherapy Psychosomatics, 73(5), 276-285  Vos, P J., Visser, A P., Garssen, B., Duivenvoorden, H J., & de Haes, H C (2007) J Psychosocial Oncol, 25(4), 37-60 Neutral Effects  More distressed patients seem to benefit most from group interventions Both Goodwin et al (2001) and Boesen et al (2005) found that women who were initially more distressed found greater benefit from the group intervention  Goodwin, P J., Leszcz, M., Ennis, M., Koopmans, J., Vincent, L., Guther, H., et al (2001) The effect of group psychosocial support on survival in metastatic breast cancer N Engl J Med, 345(24), 1719-1726  Boesen, E H., Ross, L., Frederiksen, K., Thomsen, B L., Dahlstrom, K., Schmidt, G., et al (2005) Psycho educational Intervention for patients with cutaneous malignant melanoma: a replication study Journal of Clinical Oncology, 23(6), 1270-1277  Example of distressed patient Distressed patient Who participates in Groups Support group members tend to be        Female; Younger; More educated; Without a partner, Comfortable in using formal support, Held more positive beliefs about group benefits, Felt ‘others’ were supportive of groups,’ Perceived less difficulty in joining a group, Felt more distressed & anxious about having cancer, Lack of support from a ‘special person,’ Used active coping techniques, such as planning, and reframing problems Grande, G E., Myers, L B., & Sutton, S R (2006) How patients who participate in cancer support groups differ from those who not? Psycho-Oncology, 15(4), 321-334 Can group be harmful? “Negative group experiences can result from any interaction,” Galinsky, M J., & Schopler, J H (1984) Social Work in Health Care, 20, 77-95        Open communication can feel scary, and threatening; Feeling pressure to conform or stress about group obligations; Group experiences may leave members feeling overwhelmed, less adequate; Lack of group direction makes group members uneasy; Feeling bothered by disruptive or controlling members; Fears of seeming ‘stupid,’ bothers many group members; “Is this group for me?” may mean, “I don’t feel understood, here.” Coping with problems in group       Group Leader tasks include the need to reinforce a positive image of each group member Fears of ‘feeling stupid,’ can be lowered by the leader’s positive regard for each person’s worry and question Help each group member locate a ‘similar other,’ within the group Difficult group members can be helped when group leaders address the underlying fear, anger, or sadness that isn’t being disclosed directly “It feels to me (leader says), that something may be bothering you How have things been for you, this week? The attacking group member may be projecting the most disliked aspect of himself or herself to the group member in the room By redirecting the attention back to the attacker’s feelings at the moment, the group leader shows the group that they are safe to explore their own feelings In Summary-      Group interventions have been found effective in improving patient mood, fatigue, and social support, in many studies Patients with the highest percentage of emotional distress are likely to appreciate what groups offer them, while patients feeling less distressed by a cancer diagnosis or treatment may benefit less Patients can be harmed in support groups, when insensitive comments made are a reflection of the ‘sayers,’ problems Leaders can learn to manage difficult moments in groups by: 1) enquiring into the feelings of the aggressor, “What’s coming up for you, today?” When feelings have been identified and expressed, the group leader can reframe the attack as a worry or an unexamined turf issue that reflects a difference in priorities “How did the rest of you hear experience this?” Group leader defuses the tension by helping both sides express their feelings and by reframing the problem as a semantic misunderstanding or priority difference “People are never the problem, people have problems.” Watts, R (1998) Tulsa, Oklahoma: Honor Books We end with a picture of a successful group, 2003-2009 [...]... pressure to conform or stress about group obligations; Group experiences may leave members feeling overwhelmed, less adequate; Lack of group direction makes group members uneasy; Feeling bothered by disruptive or controlling members; Fears of seeming ‘stupid,’ bothers many group members; “Is this group for me?” may mean, “I don’t feel understood, here.” Coping with problems in group       Group Leader... study Journal of Clinical Oncology, 23(6), 1270-1277  Example of distressed patient Distressed patient Who participates in Groups Support group members tend to be        Female; Younger; More educated; Without a partner, Comfortable in using formal support, Held more positive beliefs about group benefits, Felt ‘others’ were supportive of groups,’ Perceived less difficulty in joining a group, Felt...Stanford study finds improvement    Classen, C., Butler, L D., Koopman, C., Miller, E., DiMiceli, S., Giese-Davis, J., et al (2001) Supportiveexpressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial Arch Gen Psychiatry, 58(5), 494-501 125 breast cancer patients with metastatic disease were studied 64 intervention group with a 1 year group. .. 61 controls Group members showed a decline in IES trauma (stress) Benefits of psychosocial oncology care: Improved quality of life    “Interventions to treat distress and improve quality of life in cancer patients are widely available, effective, and standardized.” “Given the bulk of literature available detailing the efficacy of various types of interventions for patients at all points of the illness... problems in group       Group Leader tasks include the need to reinforce a positive image of each group member Fears of ‘feeling stupid,’ can be lowered by the leader’s positive regard for each person’s worry and question Help each group member locate a ‘similar other,’ within the group Difficult group members can be helped when group leaders address the underlying fear, anger, or sadness that isn’t... Patients with the highest percentage of emotional distress are likely to appreciate what groups offer them, while patients feeling less distressed by a cancer diagnosis or treatment may benefit less Patients can be harmed in support groups, when insensitive comments made are a reflection of the ‘sayers,’ problems Leaders can learn to manage difficult moments in groups by: 1) enquiring into the feelings of. .. services to cancer patients.” Carlson, L E., & Bultz, B D (2003) Health and Quality of Life Outcomes, 1(8), 1-8 Neutral Effects  The patients who benefit most from groups tend to be those who are most distressed  Vos et al 2004, 2007, found that when comparing patients without high distress in support groups, versus patients held in control, that well-adjusted women diagnosed with breast cancer did... be bothering you How have things been for you, this week? The attacking group member may be projecting the most disliked aspect of himself or herself to the group member in the room By redirecting the attention back to the attacker’s feelings at the moment, the group leader shows the group that they are safe to explore their own feelings In Summary-      Group interventions have been found effective... benefit from the group intervention  Goodwin, P J., Leszcz, M., Ennis, M., Koopmans, J., Vincent, L., Guther, H., et al (2001) The effect of group psychosocial support on survival in metastatic breast cancer N Engl J Med, 345(24), 1719-1726  Boesen, E H., Ross, L., Frederiksen, K., Thomsen, B L., Dahlstrom, K., Schmidt, G., et al (2005) Psycho educational Intervention for patients with cutaneous malignant... Felt more distressed & anxious about having cancer, Lack of support from a ‘special person,’ Used active coping techniques, such as planning, and reframing problems Grande, G E., Myers, L B., & Sutton, S R (2006) How do patients who participate in cancer support groups differ from those who do not? Psycho-Oncology, 15(4), 321-334 Can group be harmful? “Negative group experiences can result from any interaction,” ... Psychooncology 2010 Sep [Epub ahead of print] Results of this study: In out of studies of cognitive behavioral therapy, the Quality of life improved when patients were provided group therapy immediately after...Overview of Effects of Groups Positive effects improves mood and knowledge; lowers stress, anxiety, depression, less vomiting and pain Neutral effects -less needy patients experience less of benefit... controlling members; Fears of seeming ‘stupid,’ bothers many group members; “Is this group for me?” may mean, “I don’t feel understood, here.” Coping with problems in group       Group Leader tasks