In Search of Process: Exploring Group Work and Relatedness in a Group Intervention for Breast Cancer Patients

Allen Sherman, PhD, and Stephanie Simonton, PhD, CGP

In recent years, group services for cancer patients have become increasingly popular. A growing literature suggests that professionally led group interventions may be effective for a wide range of patients, particularly those with higher levels of distress. Controlled outcome studies point to improvements in mood, coping, health-related quality of life, and medical information (Fawzy & Fawzy, 1998; Meyer & Mark, 1995; Trijsburg, van Knippenberg, & Fijpma, 1992). To date, however, very little attention has focused on group process as opposed to group outcomes. Surprisingly few published studies have examined the shifting dynamics and patterns of interaction that characterize various types of group interventions for cancer patients, what shapes these processes, or how they relate to subsequent outcomes.

Over the past few years, supported in part by the Group Psychotherapy Foundation, we have been studying the use of groups for women with newly diagnosed breast cancer. In a recent project, participants with nonmetastatic disease (stage I-IIIa) were randomized to a routine care condition or to a short-term therapy group that convened weekly for 12 weeks, followed by three monthly booster sessions. Eighty-seven women were enrolled in the program, 10 of whom died or dropped out during the study. The groups were conducted by doctoral-level clinicians experienced in group therapy, in accord with a treatment manual. The groups focused on support, emotional expression, coping skills, and existential issues. Preliminary findings suggest that, by the end of the intervention, women who received the group services and those who received routine care both experienced improved functioning. However, participants in the group program experienced a range of favorable outcomes relative to their peers in the control condition, including significantly reduced concerns about breast cancer, enhanced coping, increased social support, heightened relationship satisfaction, and marginally increased stress-related growth. There were no differences in global distress between the two conditions, but women in the group program reported less anxiety. Results concerning longer-term outcomes are pending.

We also examined group process variables, to learn about some of the intriguing relational aspects of the group. These findings are regarded as preliminary, given the small samples available for within-group analyses. Nevertheless, they provide interesting hints about process dimensions of short-term group therapy for breast cancer patients.

The two process variables we discuss here are: "group work," or the positive working alliance within the group; and "relatedness," or the perception of closeness and comfort within the group (MacKenzie & Tschuschke, 1993). These concepts reflect distinct, clinically important aspects of group functioning (Burlingame, MacKenzie, & Strauss, in press). We examined these dimensions by using brief questionnaires that have often been used in mental health settings, though rarely in medical settings. Group work was assessed by the engagement scale from the Group Climate Questionnaire (GCQ; MacKenzie, 1981), which asked participants about their views of the group-as-a-whole. Relatedness was measured by the cohesion scale from the Curative Climate Instrument (CCI; Fuhriman, Drescher, Hanson, Henrie, & Rybicki, 1986), which asked patients to rate their individual experience in the group. Consistent with the call to move beyond assessing group process at only a single point in time (Burlingame et al., in press), these measures were completed by most participants at four intervals: week 4, week 8, week 12 (the end of the weekly meetings), and week 26 (the end of the booster sessions).

As expected, the group work and relatedness measures were moderately correlated, indicating that these concepts overlap but each contributes unique information about the nature of the group. Overall, participants portrayed the groups as quite high on group work (engagement) and moderately high on relatedness (cohesion). In other words, patients viewed the members of the group as working productively and as closely connected with each other. Group members appeared to be in fairly high agreement about these ratings (i.e., there was relatively little variability). Over the course of the program, both group work and relatedness increased significantly. The changes in group work occurred gradually, with nonsignificant increases at each time of assessment, while relatedness increased significantly during the early phase of treatment (from the first to the second assessment) and then increased more gradually. Consistent with a group development perspective, both ratings leveled off in the final segment of treatment, as participants ended their weekly meetings and transitioned through booster sessions to termination.

What variables seem to predict these processes within the group? Group work, or the therapeutic environment, is often viewed as a property of the group-as-a-whole rather than of individuals (e.g., Burlingame et al., in press; MacKenzie & Tschuschke, 1993). Here, however, we shifted our perspective to the individual participants-that is, we examined associations between individual pre-treatment characteristics and individual perceptions of the group. Interestingly, several patient characteristics, assessed prior to group enrollment, were associated with group processes as they unfolded during the early course of treatment (week four). High levels of group work were reported by women who had scored high in optimism (Lot Orientation Test, Scheier & Carver, 1985) and active behavioral coping (Dealing with Illness, Fawzy et al., 1990), and low in emotional distress (Brief Symptom Inventory, Derogatis, 1993) prior to entering the group. We also explored predictors of group relatedness. High levels of relatedness were reported by women who had demonstrated greater communication about cancer in the family (Openness of Communication about Cancer in the Family, Mesters et al., 1997), active cognitive coping (Dealing with Illness), and stress-related growth (Park, Cohen, & Murch, 1996) prior to enrolling in the group. Thus, these two dimensions of group process were predicted by different patient characteristics. Overall, however, participants with stronger personal and coping resources perceived the group as more engaged in therapeutic work and more closely bonded.

Finally, we explored whether patients' perceptions of the group were associated with how well they fared. Do these process measures predict treatment outcomes for women with breast cancer? We examined relationships between outcomes assessed at the end of the program and group processes early in treatment (week 4). We also examined connections between outcomes and group process variables late in treatment (week 26). After controlling for pretreatment scores, neither group work nor relatedness was strongly predictive of patient outcomes. At least in the short-run, group process variables seemed to have little impact on adjustment to illness in our small sample of breast cancer patients.

These findings are only suggestive. However, they illustrate that important facets of group process can be measured in a group for cancer patients, that these patterns change over time, and that they may be influenced by the individual characteristics of the participants. The strong working alliance and high level of relatedness demonstrated by these participants is reassuring. They perceived that they were doing important therapeutic work and felt deeply connected with each other. Women's perceptions of the group were also colored by the personal and relational qualities that they brought to it. No doubt these characteristics helped shape the group experience in important ways (e.g., Piper, McCallum, & Azim, 1992). These findings seem to affirm the importance of devoting extra effort to participants who enter the group with fewer personal resources (e.g., those who are less expressive and have fewer coping skills).

The fact that these process variables were not strongly related to treatment outcomes was somewhat surprising. In research with psychiatric inpatients, other investigators (MacKenzie & Tschuschke, 1993) similarly failed to uncover a connection between group work and treatment outcomes, although relatedness was associated with outcomes. In our patient sample, it is possible that these relationships may become more robust over time (i.e., the impact of process variables may become more evident with longer-term follow-up). It is also possible that a different type of group intervention, perhaps one focused more intensely on intra-group interactions and less on coping skills and health promotion, may lead to stronger associations between group process and outcome. Similarly, different insights might have emerged had we examined different process variables (e.g., observer ratings, patient-therapist interactions) (Earley, 1999; Fuhriman & Packard, 1986). In any event, it is clear that this is a rich avenue of inquiry. We hope others are encouraged to explore process dimensions of group treatment with medical patients-an exciting area that has been sorely neglected.

This study was supported in part by grants from the Group Psychotherapy Foundation, the Breast Cancer Research Program, the Arkansas Chapter of the Susan G. Komen Foundation, and the UAMS Medical Research Endowment Fund.

Allen Sherman, PhD, is Clinical Director of Behavioral Medicine and Associate Professor of Otolaryngology at Arkansas Cancer Research Center, University of Arkansas for Medical Sciences. Stephanie Simonton, PhD, CGP, is Director of Behavioral Medicine and Associate Professor of Otolaryngology at Arkansas Cancer Research Center, University of Arkansas for Medical Sciences.  

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This article was published in the June/July 2002 issue of The Group Circle.