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Section 24
Group Psychotherapy for Cancer Patients

Question 24 | Test | Table of Contents

Group psychotherapy
Group psychotherapy is not a new form of psychological intervention. Pratt, at the turn of the century, used it with tubercular patients and Lazell treated schizophrenic and manic-depressive patients in the 1920s in groups (Klein, et al., 1992). During the 1930s and 1940s, practitioners continued to experiment with and popularize group work. The modality matured as knowledge grew about social relations and group dynamics. T-groups ('T' for training in human relations) and later, encounter groups testify to the ongoing interest in learning interpersonal skills in this type of setting. Group psychotherapy varies in its emphasis on: intrapersonal/intrapsychic, transactional/interpersonal, and the integral/group-as-a-whole processes. Klein et al. (1992) discuss contributions from: object relations, self-psychology and social systems theories in their handbook of contempory group psychotherapy. Rutan and Stone (1993) have integrated individual psychoanalytic theory with group therapy by focusing upon the use of group interactions as a means of clarifying individual as well as group transferences and resistances. Thus, group psychotherapy has evolved during the twentieth century into a variety of approaches to helping people improve the quality of their lives.

Today, group psychotherapy encompasses numerous types of treatment (e.g. psychoeducation, cognitive-behavioural therapy, supportive-expressive therapy, psychodynamic). It may differ in terms of: group composition (homogeneous/heterogeneous), format (e.g. open/closed), duration (long-/ short-term) and goals (personality change, stop alcohol abuse). While it has been used to treat psychosocial dysfunction for a long time (especially with psychiatric patients; Yalom, 1985; 1995), its use with medical patients is relatively new (Antoni, 1997). Nonetheless, it may provide a forum for patients to address their concerns and learn how to live with their disease. Treating patients in groups may be less costly, it reduces social isolation and empowers patients to assist one another. Importantly, it is based on the assumption that medical patients, for the most part, are not mentally ill--they are 'normal' individuals facing an 'abnormal' situation. They may have intra- or interpersonal difficulties that predate their diagnosis, but these mirror population norms. Thus, the focus of treatment is limited to illness-related problems. Typical themes discussed in groups include doctor-patient communication, relationships with family and friends, coping with medical treatments and side effects, self-esteem, grieving losses and the threat of death.

In this section we will selectively review and critique randomized clinical trials (RCT) conducted with four diseases: cancer, AIDS, coronary heart disease and arthritis. We could have included other areas (e.g. eating disorders, addictions), but decided that our message could be communicated without being exhaustive. A literature search of Medline and PsychInfo, for the years 1995-1998 revealed that psychotherapy was studied most in cancer, followed by addictions and AIDS. Excluded in this paper are studies without random assignment to groups; these were abundant.

Cancer
Bottomley (1997) reviewed two decades of group interventions with adult cancer patients and noted that, of 27 studies located, two broad types of approaches were used: supportive or structured psycho-education. The former encourages patients to acknowledge their experiences and express their emotions with other patients, the latter uses cognitive and behavioural techniques to allow improvements in patients' adaptation to disease via learning coping skills and stress reduction techniques (e.g. relaxation training). Of the 27 studies reviewed, 13 were RCTs; of these, sample sizes varied from 20 to 199, with a mean of 89 patients. Only five of the 13 were published in the past decade (1988-1998). In her summary, Bottomley indicates that the various group interventions offer mental health benefits, irrespective of stage of diagnosis or medical treatments compared to patients in control groups.

Mental health benefits following group intervention with a mental health professional, while important, are not surprising. What startled the research community was the results of a ten-year, prospective study reported by Spiegel et al. (1989) in The Lancet, demonstrating that the survival of women with metastatic breast cancer was twice as long (36.6 months) for women participating in group psychotherapy compared to those who were randomly assigned to standard medical care (18.9 months). In this study, 109 metastatic breast cancer patients were randomly assigned to either support or control groups. The groups were run by a psychiatrist and social worker, for weekly 90-minute sessions. Six to ten women met and shared their concerns regarding treatment, illness, family and social problems in an unstructured manner and they learned self-hypnosis as a means of controlling pain. Pre- and post-treatment measures of mood states, self-esteem, coping and pain, among other psychosocial variables were collected. Evaluations at four and eight months showed no significant group differences; however, at 12 months, the group psychotherapy patients showed significantly better coping styles, fewer phobias and less confusion and fatigue. One explanation of this 'delayed' effect is that, with practise, people integrate the therapeutic changes into their lives. If this is a consistent finding, evaluations must be repeated for relatively long periods of time. The unexpected (Spiegel, 1993) long-term survival differences have stirred much interest and have encouraged others to attempt to replicate the work (e.g. Goodwin et al., 1996).

A study reported by Ilnyckyj et al. (1994) is of interest for discussion sake, because at first glance one may conclude that survival was not impacted by psychotherapy. In this study, 127 cancer patients with mixed diagnoses, mixed gender and at different phases of their diseases were randomly assigned to support or control groups. The groups were run by a social worker without employing a theory-driven therapy. In fact, some groups were professionally led for six months, others for three months and then encouraged to lead themselves for another three months, and some had no leader at all (self-help support group). High attrition rates were reported (overall 20.5%), especially in the self-help group. The mean survival rates for the professionally led and self-help groups combined were 70.7 and 62.0 months, respectively; these were not statistically different from the control group (82.4 months). Before considering this result as a failure to replicate the Spiegel et al. (1993) study, one must examine the methods employed. First, the intervention was inadequate. Second, the groups were not homogeneous. Third, the sample was biased both in terms of patients' willingness to participate (only 31.7% approached agreed) and a high rate of attrition. No data were presented regarding changes (or lack thereof) of psychosocial variables. Also, self-hypnosis was not integrated into treatment; this may be one key treatment component (Kirsh et al., 1995).

Fawzy et al. (1990) conducted an RCT with newly diagnosed malignant melanoma patients which tracked both psychosocial and immunological changes following a six-week structured psychiatric group intervention (described in Fawzy et al., 1997). Specifically, six weeks and six months after the psychosocial intervention, patients reported less psychological distress, improved coping methods, and the following immune changes: significant increases in the percentage of large granular lymphocyte (defined as CD57 with Leu-7) and natural killer (NK) cells (defined as CD16 with Leu-11 and CD56 with NKH1) along with indications of increase in NK cytotoxic activity, and a small decrease in the percentage of CD4 T cells. While not linked directly to health outcomes, this study is important because it examined possible mechanisms which may explain why some patients in psychotherapy may have better health outcomes.

Interestingly, affective states (e.g. depression, anxiety) were significantly correlated with immunological changes. Thus, it is plausible that psychotherapy decreases psychological distress, which alters immune function and potentially the course of the disease.

Personal Reflection Exercise #10
The preceding section contained information regarding group psychotherapy for cancer patients. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Focused Group Analytic
Psychotherapy: An integration
of clinical experience and research

Lorentzen S. (2022). Focused group analytic psychotherapy: An integration of clinical experience and research. Journal of clinical psychology, 78(8), 1613–1623.

Peer-Reviewed Journal Article References:
Dolgin, R., Riva, M. T., & Owen, J. (2020). Clinical congruence of cohesion in group psychotherapy. Professional Psychology: Research and Practice, 51(6), 598–605.

Griesemer, I., Moore, E., Khan, C., Roche, M., Henderson, G., & Rini, C. (2019). Psychological adaptation to diagnostic genomic sequencing results: The role of hope fulfillment. Health Psychology, 38(6), 527–535.

Kivlighan, D. M. III, Aloe, A. M., Adams, M. C., Garrison, Y. L., Obrecht, A., Ho, Y. C. S., Kim, J. Y. C., Hooley, I. W., Chan, L., & Deng, K. (2020). Does the group in group psychotherapy matter? A meta-analysis of the intraclass correlation coefficient in group treatment research. Journal of Consulting and Clinical Psychology, 88(4), 322–337.

Manne, S. L., Siegel, S. D., Heckman, C. J., & Kashy, D. A. (2016). A randomized clinical trial of a supportive versus a skill-based couple-focused group intervention for breast cancer patients. Journal of Consulting and Clinical Psychology, 84(8), 668–681.

QUESTION 24
According to Dobkin & Costa, what is the difference between supportive and structured psycho-education interventions in group psychotherapy? To select and enter your answer go to Test.

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