Groups and Medical Illness

    •    Advanced breast cancer: No durable evidence for survival impact but
    significant benefits with regard to psychological distress; coping with the
    illness; managing pain more effectively and managing fear (Spiegel et al.,
    1989; Goodwin et al., 2001).

    •    Early stage breast cancer: Improved social support and reduced
    psychological distress but with a caution that quality of leadership is
    important so as to not stimulate affective arousal beyond the capacity of
    the individuals and the group to manage. Improvement with stress ratings
    and improvement with coping may reduce illness recurrence (Antoni et
    al.,  2006; Cohen et al.,2007; Classen et al., 2008).

    •    Irritable bowel syndrome: Groups improve pain ratings, psychological
    distress, and quality of life (Blanchard et al., 2007)

    •    Chronic pain: Groups improve pain management, mood and functional
    impairment (Lamb et al., 2010).

    •    Medically unexplained symptoms: 20% of patients present to family
    physicians with unexplained medical symptoms causing significant distress
    to patients and frustration to care providers. Collaborative care linking
    family physicians and psychosomatic specialists delivered a brief group
    intervention, integrative in nature, that showed significant impact with
    regard to reducing health anxiety; psychological distress; reduced
    healthcare visits with economic benefits and improved health-related
    quality of life (Schaefert et al., 2013).

    •    Heart failure: In general, interventions of all formats improve health-
    related quality of life but there is particular benefit in a humanistic,
    existential group intervention which has showed significant impact post-
    myocardial infarction with regard to significantly improved survival,
    medical and psychological outcomes (Grady et al., 2014; Orth-Gomer et
    al., 2009; Roncella et al., 2013).

    •    HIV: Group therapy improves psychosocial functioning and well being
    in men with HIV (Roussaud et al , 2007) and in diverse cultural settings
    (Molassiotis et al, 2002). Older adults with HIV demonstrated significant
    improvements in depression in response to supportive-expressive and
    coping-focused group therapy delivered by phone (Heckman, et al.,
    2013).

    •    Internet groups are also useful and, as illustrated in an asynchronous
    group for adult survivors of pediatric cancers, employing a narrative
    approach also enhanced social support. Outcomes demonstrated were
    reduced post-traumatic stress symptoms; reduced anxiety; and reduced
    fear of recurrence (Seitz et al., 2014).

    •    Internet and telepsychiatry groups may be particularly important and
    accessible therapy for those who are physically too unwell to travel
    (Applebaum et al., 2012).

Contemporary healthcare is emphasizing greater integration and collaboration between medical and psychological care, recognizing the bilateral burden and the likely co-occurrence of both dimensions of illness. Clinical attention to this interface has expanded throughout medicine, building upon the early roots of groups for individuals with cancer and HIV. This trend now includes chronic disease management; pain; medically unexplained symptoms and heart disease as illustrations. It is important throughout to recognize that medical illness is not homogeneous by diagnosis. Not all that suffer a medical illness are psychologically distressed and it is most relevant to gear interventions to those who experience higher levels of psychological burden of distress. There is growing awareness as well of the need to modify group interventions to be culturally adaptive and recognize the unique ethnocultural contributions to the experience of illness. Groups are also being used on-line, both with synchronous, interactive group interventions and asynchronous groups that provide opportunities for self-expression, support and education.

It is useful to conceptualize group interventions as reflecting the tripartite model of coping (Folkman & Greer, 2000). This model emphasizes the value of emotion-based coping with regard to emotional expressiveness; social support and social integration. A second component centers on problem-based coping which emphasizes acquisition of knowledge and structured coping skills. A third component addresses the dimension of meaning-based coping for help in those situations where adversity cannot be overcome but rather must be engaged as a challenge. This last domain emphasizes existential and humanistic dimensions and the pursuit of meaning in the face of serious adversity.

These three dimensions gain expression in a variety of group models, reflected in supportive expressive group therapy, cognitive behavioral group therapy, psycho-educational approaches, and self-management groups. In-depth psychological approaches and psychodynamic understanding weave their way through both supportive expressive group therapy and cognitive behavioral group therapy. A close look at the manuals that guide these interventions underscore an integrative approach in virtually all instances. A meta-theoretical orientation and integration captures most models of intervention, recognizing the objectives are to assist patients rather than adhere to an ideological singularity.

Groups can be open-ended for those with chronic and life-threatening illness or, more typically, are time-limited running between 8 - 26 sessions for individuals with earlier stages of illness. The group is typically used as a setting rather than as an agent for change.  Feedback is focused on the illness and coping rather than on interpersonal or relational functioning. Throughout, the objectives in treatment are to improve both the physical and  psychosocial dimensions of illness. Psychosocial dimensions include health-related quality of life, depression, anxiety, traumatic stress symptoms, and general levels of distress. Quality of life is complicated and often hard to measure (Sherman et al. 2010).

Efforts at understanding how groups achieve their effectiveness remain somewhat elusive but may be economically understood as improving self-efficacy and the individual’s capacity to engage adversity constructively and actively (Bandura, 1982). This involves marshaling external and internal resources to confront challenges in ways that improve the individual’s sense of personal effectiveness in his own life which is often challenged by severe illness and mortal threats. Economic benefits are also an associated component of outcome with better utilization of medical care and more appropriate use of medical care. Improving compliance with specific courses of treatment may also be one of the mediators that govern the effectiveness of group interventions for medical illness (Dinkel et al., 2012).

As is true in all group therapies, the quality of the group experience will be affected by group cohesion and the skill and effectiveness of the group's leadership (Kissane et al., 2007). 

References:

Antoni, M., Wimberly, S., Lechner, S., et al. (2006). Reduction cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. The American Journal of Psychiatry, 163, 1791-1797. DOI 10.1176/ajp.2006.163.10.1791.

Applebaum, A.J., Lichenthal, W.G., Pessin, H.A., et al. (2012). Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer. Psycho-Oncology, 21, 1195-204. DOI 10.1002/pon.2013.

Bandura, A. The assessment and predictive generality of self-percepts of efficacy. (1982). Journal of Behavior Therapy and Experimental Psychiatry, 13, 195-199. DOI 10.1016/0005-7916(82)90004-0.

Blanchard, E.B., Lackner, J.M., Sanders, K. et al. (2007). A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome. Behaviour Research and Therapy, 45, 633-648. DOI 10.1016/j.brat.2006.07.003.

Classen, C.C., Cavanaugh, C.E., Kraemer, H.C, et al. (2008). Supportive-expressive group therapy for primary breast cancer patients: A randomized prospective multicenter trial. Psycho-Oncology, 17, 438-447. DOI 10.1002/pon.1280.

Cohen, M., & Fried, G. (2007). Comparing relaxation training and cognitive-behavioral group therapy for women with breast cancer. Research on Social Work Practice, 17, 313-323. DOI 10.1177/1049731506293741.

Dinkel, A., Herschbach, P., Berg, P., et al. (2012). Determinants of long-term response to group therapy for dysfunctional fear of progression in chronic diseases. Behavioral Medicine, 38, 1-5. DOI 10.1080/08964289.2011.640364.

Folkman, S., & Greer, S. (2000) Promoting Psychological Well-Being in the Face of Serious Illness: When Theory, Research and Practice Inform Each Other. Psycho-Oncology, 9, 11-19. DOI doi: 10.1002/(SICI)1099-1611(200001/02)9:1<11::AID-PON424>3.0.CO;2-Z.

Goodwin, P., Leszcz, M., Ennis, M. et al. (2001). The effect of group psychosocial support on survival in metastatic breast cancer. New England Journal of Medicine, 345, 1719-1726. DOI 10.1056/NEJMoa011871.

Grady, K. de Leon, C.F., Kozak, A.T., et al. (2014). Does self-management counseling in patients with heart failure improve quality of life? Findings from the Heart Failure Adherence and Retention Trial (HART). Quality of Life Research, 23, 31-38. DOI 10.1007/s11136-013-0432-7.

Heckman, T.G., Heckman, B.D., Anderson, T., et al. (2013). Supportive-expressive and coping group teletherapies for HIV-infected older adults: a randomized clinical trial. AIDS Behav, 17, 3034-44. DOI 10.1007/s10461-013-0441-0.

Kissane, D., Grabsch, B., Clarke, D., et al. (2007). Supportive-expressive group therapy for women with metastatic breast cancer. Psycho-Oncology, 16, 277-86. DOI 10.1002/pon.1185.

Lamb, S.E., Hansen, Z., Lall, R., et al. (2010). Group cognitive behavioural treatment for low-back pain in primary care. The Lancet, 375, 916-923. DOI 10.1016/S0140-6736(09)62164-4.

Molassiotis, A., Callaghan, P., Twinn, S., et al. (2002). A pilot study of the effects of cognitive-behavioral group therapy and peer support/counseling in decreasing psychologic distress and improving quality of life in Chinese patients with symptomatic HIV disease. AIDS Patient Care & Stds, 16, 83-96. DOI 10.1089/10872910252806135.

Orth-Gomer, K., Schneiderman, N., Wang, H.X., et al. (2009). Stress reduction prolongs life in women with coronary disease: the Stockholm Women’s Intervention Trial for Coronary Heart Disease (SWITCHD). Circulation, Cardiovascular Quality & Outcomes, 2, 25-32. DOI 10.1161/CIRCOUTCOMES.108.812859.

Roncella, A., Pristipino, C., Cianfrocca, C., et al. (2013). One-year results of the randomized, controlled, short-term psychotherapy in acute myocardial infarction (STEP-IN-AMI) trial. International Journal of Cardiology, 170, 132-139. DOI 10.1016/j.ijcard.2013.08.094.

Rousaud, A., Blanch, J., Hautzinger, M., et al. (2007). Improvement of psychosocial adjustment to HIV-1 infection through a cognitive-behavioral oriented group psychotherapy program: a pilot study. AIDS Patient Care & Stds, 21, 212-22. DOI 10.1089/apc.2006.0077.

Schaefert, R., Kaufmann, C., Wild, B., et al. (2013). Specific Group Intervention for Patients with Medically Unexplained Symptoms in General Practice: A Cluster Randomized Controlled Trial. Psychotherapy and Psychosomatics, 82, 106-119. DOI 10.1159/000343652.

Seitz, D.C., Knaevelsrud, C., Duran, G., et al. (2014). Efficacy of an internet-based cognitive-behavioral intervention for long-term survivors of pediatric cancer: a pilot study. Supportive Care in Cancer, 22, 2075-2083. DOI 10.1007/s00520-014-2193-4.

Sherman, K.A., Heard, G., & Cavanagh, K.L. (2010). Psychological effects and mediators of a group multi-component program for breast cancer survivors. Journal of Behavioral Medicine, 33, 378-391. DOI 10.1007/s10865-010-9265-9.

Spiegel, D., Kraemer, H.C., Bloom, J.R., et al. (1989). Effect of psychosocial treatment on survival of patients with metastatic breast cancer. The Lancet, 2, 888-891. DOI  10.1016/S0140-6736(89)91551-1.

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