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Cognitive‐ExistentialGroupTherapyforPatientswithPrimaryBreastCancer—TechniquesandThemes

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COGNITIVE-EXISTENTIAL GROUP THERAPYFOR PATIENTS WITH PRIMARY BREASTCANCER — TECHNIQUES AND THEMES

DAVID W. KISSANE,*1 SIDNEY BLOCH,2 PATRICIA MIACH,3 GRAEME C. SMITH,3 ANN SEDDON3 andNICHOLAS KEKS4

1University of Melbourne Centre for Palliative Care, Department of Medicine, Peter MacCallum Cancer Instituteand St Vincent’s Hospital, Melbourne, Australia; 2University of Melbourne, Department of Psychiatry, St

Vincent’s Hospital, Fitzroy, Victoria 3065, Australia; 3Monash University Department of Psychological Medicine,Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia; 4Monash University Department

of Psychological Medicine, The Alfred Healthcare Group, Prahran Victoria 3181, Australia

SUMMARY

We describe a model of cognitive-existential group therapy designed to be integrated over 6 months with regimensof adjuvant chemotherapy given as conventional medical treatment to breast cancer patients with stage 1 and 2disease. Our broad therapy goals are for members to develop a supportive network, work through grief over losses,improve problem solving and develop cognitive strategies to maximise coping, enhance a sense of mastery over lifeand re-evaluate priorities for the future. Specific group themes include death anxiety, fear of recurrence, living withuncertainty, understanding treatment with chemotherapy, radiotherapy and hormone regimens, the collaborativedoctor-patient relationship, body and self image, sexuality, relationships with partner, friends and family, surgicalreconstruction, life style effects and future goals. Active coping skills are developed through teaching formalproblem solving and cognitive restructuring of automatic negative thoughts. Technical aspects of the therapy arediscussed. © 1997 by John Wiley & Sons, Ltd.

Psycho-Oncol 6: 25–33, 1997No. of Figures: 0 No. of Tables: 0 No. of Refs: 36

INTRODUCTION

Breast cancer, the most common form of cancerin women, affects 1 in 13 (Coates, 1994). Overall,7% of Australian women will be diagnosed withbreast cancer at some stage in their lives (Giles etal., 1993). Psychological and social morbidity inthese women is high. Indeed, in the first yearfollowing mastectomy up to a third of womenhave mood or sexual problems severe enough towarrant psychiatric help (Maguire et al., 1978).Dean (1987) found that one year after mastec-tomy, 18% of patients have suffered minor and5% major depression. Women with breast cancergenerally show greater distress, concern with

physical symptoms, anxiety, and inter-personal difficulties, and more negative attitudestowards themselves and their future than controlsubjects (PABCSG, 1987). The expectation thatconservation surgery would be associated withreduced psychiatric morbidity has generally notbeen fulfilled (Fallowfield et al., 1990), the inher-ent fears in cancer ostensibly being more harmfulthan a change in body image. Thus, these studiesclearly demonstrate that psychosocial morbidity isa major concern in patients with breast cancer.

Interventions that facilitate more effectiveadjustment and coping should reduce this morbid-ity and improve quality of life. Early trials ofgroup therapy for patients with advanced cancerdid lead to improved quality of life (e.g. Spiegel et

* Correspondence to: Professor David Kissane, Centre for Palliative Care, 104 Studley Park Road, Kew, Victoria 3101,Australia.Contract grant sponsor: Research and Development Grants Advisory Committee of the Australian CommonwealthDepartment of Human Services and Health. Contract grant number: HS 302.

PSYCHO-ONCOLOGY, VOL. 6: 25–33 (1997)

CCC 1057–9249/97/010025–09 $17.50 Received 3 January 1996© 1997 by John Wiley & Sons, Ltd. Accepted 3 July 1996

al., 1981). Moreover, a 10-year follow-up showeda significant survival advantage for group therapypatients compared with women receiving conven-tional clinical care, highlighting the beneficial roleof psychological well-being (Spiegel et al., 1989).Several further studies have suggested a clearassociation between mental attitude to cancer andsurvival (Mulder et al., 1992).

A range of therapeutic models — individual,group and family — have emerged since the1970s. There seems to be no difference in outcomebetween treatments delivered individually andthose delivered in groups (Farash, 1979; Cain etal., 1986; Anderson, 1992; Krupnick et al., 1993).Perhaps the first model most suitable for applica-tion to cancer patients is that described asexistential psychotherapy by Yalom (1980), inwhich anxiety about death and uncertainty ofpurpose are confronted. This approach has beenincorporated into supportive-expressive grouptherapy (Spiegel and Spira, 1993), linked withoccasional family sessions. Moorey and Greer(1989) have opted to adapt cognitive-behaviouraltherapy for their cancer patients and applied it,individually, to high risk patients. Another modelthat promotes the use of active coping strategieshas been developed by Fawzy et al. (1994). Apivotal question immediately arises: which modelis the most appropriate for the respective stagesof breast cancer?

We see a role for a model of therapy whichmeets the needs of women with early stage breastcancer, whose concerns may differ considerablyfrom those with metastatic disease. Since theintroduction of mammographic screening, womenwhose cancer is diagnosed earlier are more likelyto survive; it is estimated that two thirds ofwomen with breast cancer will survive the disease(Tabar et al., 1993). Complex treatment compris-ing hormones, chemotherapy and radiotherapyare routinely used following initial surgical man-agement. Such programs add to the strain of theexperience. We, therefore, set out to develop anew psychological model which could be inte-grated into medical management and combinedthe existential and cognitive psychotherapy tradi-tions. In so doing we have selected those aspectsof the two theories we consider central in meetingthe needs of patients with early breast cancer. Wehave particularly applied a group model, not onlybecause of cost-effectiveness but also given themutual support members can provide.

Our purpose in this paper is to describe this

cognitive-existential approach in the hope ofpromoting and exchanging ideas in the quest foran optimal model of psychotherapy for womenwith early breast cancer. The following accountstems from our pilot work covering seven groupsand 48 patients.

THE THERAPEUTIC MODEL

Goals of therapy

We identified six goals to fulfil our overall aim ofimproving patients’ quality of life: promoting asupportive environment; facilitating grief workover multiple losses; altering maladaptive cogni-tive patterns; enhancing problem solving andcoping skills; fostering a sense of mastery; andproviding an opportunity to sort out priorities forthe future. In pursuing these goals, we recognisethe limits of the enterprise and thus avoid the everpresent temptation to delve into long-standingpersonality difficulties; these would be moreappropriately tackled in long-term insight-ori-ented individual or group psychotherapy.

Process

Patient selection and group formation. In addi-tion to receiving referrals directly from surgeonsand oncologists, we are able to inform patientsabout the availability of the group by building andmaintaining a close working liaison with severalchemotherapy and radiotherapy units. We checkthat potential members have early stage breastcancer to ensure homogeneity, and confirm thatthey have sufficient English speaking skills toparticipate effectively. Groups consist of six toeight patients and two therapists and meet weeklyfor 90 minutes for a total of 20 sessions. To avoiddelay in launching groups, it has proved distinctlyadvantageous to recruit simultaneously from afew neighbouring hospitals. To this end, we haveinitiated a collaborative network covering tenmetropolitan hospitals affiliated to the two medi-cal schools in Melbourne. The group approach hasproved acceptable to two thirds of women invitedto participate; the remainder either indicate thatthey are coping satisfactorily or that the prospectof group therapy is unappealing or anxiety-

26 D. W. KISSANE ET AL.

provoking; on occasion various logistical compli-cations have precluded participation.

Therapists. Therapists are recruited from themental health professionals’ disciplines of psy-chology, psychiatry and social work as well asnursing. Motivation and a deep interest in psycho-oncology are regarded as key criteria in selection.We arrange that one co-therapist be a woman,who can more readily react sensitively to a rangeof gender issues that arise. Therapists are trainedin a series of workshops, applying a detailedmanual especially prepared for this form of grouptherapy (available from the authors). Our manualis a 68 page document comprising the followingchapters: background, study protocol, goals oftherapy, establishment of groups and generalguidelines, themes specific to breast cancer, thecognitive approach and problem members ingroups. Weekly supervision follows throughouttheir initial group experience. Once trained,therapists meet monthly with a supervisor toenhance their developing skills and to ensureconformity with the manual; this permits a flexi-ble approach but within the context of ourobjectives and goals. Therapists take responsibil-ity for establishing and maintaining group rulesand norms, and for involving all members. Over-all, therapists are relatively more active than is thecase in psychodynamic group therapy.

Co-therapists review each session includingaudio and video-taped material when these areavailable. Process notes are prepared for super-vision in the course of these reviews.

Preparation. Preparation of women selected forgroup therapy is undertaken individually, sopermitting therapists to become acquainted withthem and to map out their wishes and goals. Fromthe outset, therapists counter the widespreadnotion of unrealistic ‘positive thinking’, indicatingthat the group is a forum to share concerns andfears, deal with losses and to disentangle mean-ingful priorities. The therapists hasten to reassuremembers who could be concerned about beingoverwhelmed or harmed by group participation.Indeed, an optimistic message about the benefitsexperienced by previous groups is imparted.Customary norms about confidentiality, punctual-ity and apologies for absence are mentioned. Weexplain that contact between members is notrestricted to the sessions as they are encouraged

to meet informally over light refreshments aftereach session.

During this phase, we invite the women tocommit themselves to therapy, but also suggestthat should any ambivalence arise, they shouldfeel free to share this in the group. Finally, itproves helpful for members to anticipate differ-ences as well as shared features in the group.

The group in practice. Groups progress throughthree developmental phases: beginning, middleand end. During the initial phase, therapistsactively promote the therapeutic factors of self-disclosure, cohesion and recognition of the uni-versality of their experience, thus overcoming anysense of isolation. In the middle phase, furthervicarious learning and self-disclosure are high-lighted as we confront anxiety about death, grievelosses, seek more adaptive coping through thecognitive model, instil hope and promote a senseof mastery. Information exchange, altruism, andmutual support are other powerful mid-phasetherapeutic mechanisms. In the final phase, lossand grief are revisited as the group’s end ismourned, but this is balanced by a reappraisal ofpriorities and commitment to the future. Theevolution of a typical group is described in thesections that follow.

Launching the group. After members introducethemselves, they share their expectations andrelate their experience of having breast cancer.This ‘go-round’ is invariably poignant as membershonestly express their feelings. One woman, forexample, opened the inaugural meeting byexclaiming ‘Can I go first? It will help me getthrough the session. I’m divorced, a mother oftwo, but I need to say that my second child,Steven, died of a brain tumour last year. He was12. He was a patient in this hospital. I’m stillcoming to terms with it. My own breast cancerwas discovered 8 months after Steven died. It’sbeen easier than his death. My daughter, Julia, is17 and in her last year of school. My mother alsohad breast cancer. Thank you for letting me gofirst.’

As such stories unfold, members becomeintensely interested in similarities and differencesbetween their experiences of coping with thediagnosis and treatment. Much information aboutmedical matters is exchanged during this phase.Our therapists are trained to resist assuming therole of cancer expert by inviting the group to be

GROUP THERAPY FOR BREAST CANCER PATIENTS 27

the reference point regarding accuracy of medicalaspects of the experience and how to go aboutobtaining reliable information.

The middle phase. Following the exchange of‘cancer stories’ the main work of the groupconsumes the rest of the sessions, except for a fewat the end devoted to saying farewell. Each groupcovers a series of predictable themes, most arisingspontaneously: anxiety about death; dealing withfear of recurrence and living with uncertainty;understanding treatment with chemotherapy,radiotherapy and hormones; the doctor-patientrelationship; body- and self-image; sexuality; sur-gical reconstruction; relationships with partner,family and friends; and life-style and future goals(Kissane et al., 1994).

Anxiety about death usually arises first; ther-apists aid members to acknowledge it and exploreits meaning for each person. The group thenbegins to accept cancer as a threat to life, andgrapples with the reality of finitude. Principles ofexistential psychotherapy, as highlighted byYalom (1980), are introduced to deal with deathanxiety in the recognition that, as a ‘universalgiven’, it is an inescapable part of human experi-ence. Through sharing these thoughts and feelings,members feel less threatened and isolated. Con-siderable grieving unfolds as this theme isexplored; indeed, mourning is a feature of therapythroughout the group’s life. Eventually, the typicalattitude adopted is ‘One day we will die, but untilthen we can choose to live well’.

The fear of recurrence of cancer seems univer-sal and is often linked to undue preoccupationover bodily health and function. Members, forinstance, explore the question of how to react to asomatic symptom, developing both more adaptiveproblem-solving methods and cognitiveapproaches to their fears. As the uncertaintyabout the future is faced, members consider theoptions of helplessness or taking control overtheir lives. The latter is fostered as the moreadvantageous (e.g. a sense of control of theirtreatment) with a sense of mastery ensuing; thisin turn enhances mature coping with theunpredictable.

Discussion of treatment — chemotherapy,radiotherapy and hormones — focuses on con-cerns and fears about its potential failure, risksand side-effects. Coping strategies to deal with thelatter (e.g. tiredness) are shared and treatmentcompliance thus improved. Invariably, the role of

alternative therapies is explored, including thegroup’s expectations of them. Other issuesinclude whether the women should feel blame orguilt over prior life styles, what underlies thesearch for a cure, and how best to acquireaccurate information about breast cancer and itsoptimal treatment.

The doctor-patient relationship is inevitablytackled, particularly members’ attitudes to theirprofessional caregivers. The group is encouragedto explore ways of building collaborative relation-ships with doctors and other staff, so that mem-bers actively participate in planning and imple-menting their treatment.

The breast is an obviously significant aspect ofbody and self-image; members devote much timesharing their experiences of loss. Grief workcombines with identifying new coping strategies.Negative self-appraisal is identified and chal-lenged, thus improving self-confidence. Relation-ships with partners (Sabo et al., 1986) oftenintersect with body aspects, as does sexuality(often a neglected topic). Frank exchange offeelings, particularly in the second half of theprogram, when trust is better established, pavesthe way for a clearer understanding of anydifficulties regarding sexuality (Fallowfield et al.,1990; Kaplan, 1992). Members not only come toappreciate that they are not alone with theseintensely personal sorts of problems but alsoprovide mutual support in wrestling with them.

Talking to children about their cancer is aconcern for some members; daughters of motherswith breast cancer are especially vulnerable toanxiety and need both reassurance and guidancethrough insights gained from their peers. Rela-tionships with family, both nuclear and extended,as well as with friends are considered, withemphasis on them as potential sources ofsupport.

The encounter with a life-threatening illnessleads members to evaluate their priorities andfuture goals. By recognising that only they canassume control over their lives and pursue themmeaningfully, members often develop a new senseof purpose. This focus on a spiritual dimension isactively promoted.

Integrating the cognitive position.

1. Problem solvingGroup work has traditionally employed problemsolving approaches in searching for group solu-

28 D. W. KISSANE ET AL.

tions. The focal-conflict model, for example, scru-tinises the ways in which the group evaluatesadvantages and disadvantages of potential solu-tions in terms of the tension that exists betweensatisfying members’ needs and alleviating theirfears (Stock Whitaker and Lieberman, 1964).Cohesive groups readily become a vehicle foractive problem solving, as members strive to helpeach other. Through the additional use of ahandout, the therapists guide members in apply-ing the necessary steps in this problem solvingprocess. Furthermore, therapists affirm realisticproblem solving efforts. Their repetition overmany weeks consolidates the procedure into arefined coping skill.

2. Cognitive reframing to examine and deal withnegative thoughtsA specific cognitive therapy technique of clarify-ing associated thoughts and feelings when mem-bers disclose a personal experience is introducedduring early sessions. Not only ‘Tell us how thatmade you feel’ but also ‘What went through yourmind at the time?’ is the pair of questions posed.Alternatively, therapists comment ‘It sounds likeyou had particularly upsetting thoughts when youfelt like that.’ As the group engages in therapy,such clarification implicitly reflects the cognitivemodel. Gradually, with examples concerning can-cer that reveal links between events, thoughts,behaviours and feelings manifesting in the courseof the sessions, the model is made more explicit.The elements of cognitive therapy are not didac-ticly conveyed, but rather integrated as smoothlyas possible into members’ life experiences. Beforelong, their understanding of links between experi-ence (Activating event) and thought (Belief),which in turn leads to behaviour and feeling(Consequence), is established.

Homework is added, specifically the monitoringof thoughts that accompany any distressingexperience between sessions. At no stage shouldthis be understood to promote suppression ofappropriate affects, but rather to enhance greaterunderstanding of what underlies them. Membersas a group evaluate the thoughts, discern distortedor unrealistic patterns and seek more adaptivealternatives. ‘Realistic’ rather than ‘logical’responses are valued since patients need toremain anchored in existential reality.

Throughout the middle phase, we weave inthemes pertinent to breast cancer. The goal is the

development of techniques to recognise auto-matic negative thoughts and to reframe themappropriately; ensuing skills evolve to counteranxiety about recurrence, to boost self-esteemand to encourage full engagement with life. Aseries of handouts is incorporated into this ‘cogni-tive restructuring’ phase and complements thegroup’s growing appreciation of the model. Theycover ‘Identifying automatic negative thoughts’(adapted from Moorey and Greer, 1989); ‘Thecharacteristics of automatic negative thoughts —recognising them more easily’; ‘The daily thoughtrecord for automatic negative thoughts’; ‘How tochallenge an automatic negative thought’; and‘Common thinking errors in cancer patients’.These are given out sequentially over five sessionsin the context of themes emerging in the group.

The handouts have not only promoted greateruniformity of therapeutic method but also ena-bled members to discover habitual thinking errorsand core beliefs. By having the group scrutinisethe list of thinking errors, members find theexperience less persecutory than if therapistswere to expose the faulty thoughts. Groupsbecome supportive during this process, membersidentifying with each other’s examples; associatedmodelling facilitates change.

The following three examples illustrate cogni-tive work:

(i) Distressing feelings are associated with lossof hair during chemotherapy. A member maythink she won’t be loveable, or even worse,will be rejected. This distorted thinking,involving overgeneralisation and negativeprediction, will compound her distress.

(ii) One patient recounted: ‘Each time I take atablet, it reminds me of my cancer and that’sgetting me down. I fear the cancer, so I hatetaking the medication.’ The group surmisedthat the underlying fear was of dying andsuggested that medication be seen as alifeline. One member proffered an alter-native attitude: ‘I think of cancer treatmentas the gardener, pulling out the weeds; thenI, the garden, am all the more beautiful andbetter off because of it’.

(iii) After an energetic day one memberdescribed an ache down her side and anx-iously thought: ‘Is this my cancer comingback? I’ll really be in trouble.’ She imaginedthe worst, resulting in anxiety and dimin-ished morale. An alternative thought wasoffered: ‘It’s most likely tiredness from your

GROUP THERAPY FOR BREAST CANCER PATIENTS 29

day’s exertions. A check up can be under-taken if it persists, but it will probably begone tomorrow’. Caution is always wise ifsymptoms persist; realistic appraisal is notabout false reassurance. Hence a sensiblepathway needs to be travelled betweenminimising unnecessary anxiety and practis-ing sound medicine.

A common cognitive problem encountered inevery group are distorted and confused expecta-tions and their adverse effect on various relation-ships. Feelings of anger or guilt inevitably followthe experience of unmet expectations. Recogni-tion of the ‘shoulds’ in members’ disclosures helpsthem to appreciate a habitual pattern. Expecta-tions are held by members about the community’sresponse to the cancer patient and about the rolesof health professionals, family members, partnersand friends. As these views are challenged,relationships are enhanced.

3. Anger managementRecognition of assertive rather than passiveapproaches in dealing with frustration, the avoid-ance of unrealistic expectations of others, and thebenefits of active problem solving are exploredthrough a handout on anger management. This isinvariably linked to discussions among membersof their relationships with others and their angerat having developed cancer (particularly in moth-ers of young children). Groups typically beginsuch discussions with the expectation that lifeshould be fair.

This approach to anger is definitely not aboutsuppression of affect, but rather the recognition ofanger expression and its appropriate channellinginto adaptive, constructive pathways. Groupmembers actively encourage assertiveness andaffirm the needs of members as problems of dailylife are recounted.

In summary, we have been impressed by howreadily existential themes are understood throughthe use of a reality-based cognitive therapy.Patterns in thinking that are based on long-heldcore beliefs about self and world are recognised.As members acknowledge these, they initiateappropriate revisions which empowers them toembrace life more confidently.

4. ‘Group as a whole coping’While it may appear that this cognitive approachis directed primarily at the individual member, the

development of ‘group as a whole’ solutions is acomplementary aspect of this work. Internalisingthese group-based solutions assists members evenwhen they may not always be aware of therationale of cognitive reframing. Illustrative ofthese attitudes adopted by the group are: ‘We arenot alone in living with cancer’; ‘we need to takebetter care of ourselves’; ‘one day we will die;until then we can choose to live well each day’;‘we can take control of much of our lives’; ‘wegain a lot through sharing feelings andunderstanding’.

The ending of the group. Over the last three orfour sessions, therapists direct the group’s atten-tion to the theme of endings. Three tasks flowfrom this. First, members are invited to identify‘unfinished business’ and to share the responsibil-ity of checking any unmet needs; work on themthus continues until the last. The second taskentails disclosure of feelings about loss of thegroup which necessarily reminds the members ofother key losses — of breast, health, dreams,future and perhaps life itself. Unlike the conven-tional therapy group in psychiatry, cancer groupmembers may exchange phone numbers, planreunions and often continue to meet informally.Notwithstanding, the therapists maintain a focuson the inescapable reality that the group asexperienced will cease forever. Emphasis on thismourning process is a salient feature of the groupexperience, serving as a model for dealing withloss in general. The third task is future-oriented aseach member is encouraged to reflect on how shehas changed, and to review priorities in themonths and years ahead.

Pursuit of these tasks in the final phase permitsconsolidation of members’ understanding of theirachievements, a process boosting their sense ofmorale. Thus, while the sadness felt in losing thegroup is dealt with as a model of coping with loss,gains are acknowledged and viewed as symbolicof potential for further change.

Members presenting difficulties for the group.From time to time therapists encounter memberswhose attitudes or behaviour disrupts or threat-ens to disrupt the group’s functioning (Yalom,1985). A special problem is progression of breastcancer which occasionally occurs during the life ofthe group. Although it may lead to intensedistress, members face a formidable challenge toexpress concern and care. Therapists ensure that

30 D. W. KISSANE ET AL.

any patient with progressive disease is not per-mitted to withdraw because of a sense of differ-ence to her peers and on the premise of needingfurther medical treatment. Members usuallyencounter other distressing ‘cancer stories’ butbenefit by recognising that the advance of cancerin one woman does not point to a gloomyprognosis in others. Acknowledging differencesbetween members is helpful in this context,alongside the group’s capacity to care compas-sionately for each other. Moreover, Spiegel (1993)reminds us, in talking about the dying member, ofthe reassurance felt by her fellows in observinghow they will be supported if their turn comes.

About 12% of women drop out in our experi-ence, typically after one or two sessions. Theirstated reasons relate to a lack of sense ofbelonging or a wish to avoid distress. Thedemands of weekly attendance over a 6 monthperiod also necessitate development of a sense ofgaining from the experience. When a group hasachieved a cohesiveness which respects differ-ences and functions as a container for anxiety andother distressing emotions, a safe environment isperceived despite the threats intrinsic to cancer. Aminority of members however withdraw, fail toattend, or unusually, feel extruded when differ-ences predominate. In response, the group reflectson absences, expresses concern for fellows andmay initiate contact with the absentee. We havenoted, for example, supportive members calling asingle woman who felt apart from her peers, allmarried, responding sensitively to her sense ofdifference, and holding on to her as a groupmember.

DISCUSSION

Our model, initially tested with seven groups (48patients), was generally well received. We arecurrently testing it as part of a randomisedcontrolled trial of 300 patients with stage II breastcancer (256 patients have been randomised byMay 1996, with an acceptance rate of 68%). Asthis work proceeds, we note the willingness ofmembers to attend and their gratitude for theopportunity to meet others living through compa-rable life events.

The issues that challenge patients with earlybreast cancer differ from those with metastaticdisease since survivorship or cure are distinct

possibilities for the former. Composing suchhomogeneous groups permits a focus on specificneeds. In this context, it is our impression that thecognitive-existential model is more suited topatients with early disease, whereas supportive-expressive therapy as described and applied bySpiegel and Spira (1993), with greater emphasison direct existential issues and less on cognitiveprocesses, is more apt for those with advanceddisease.

The strategies we have categorised as cogni-tively-based resemble those described by othersas ‘coping skills’ (Rose, 1989) or cognitive training(see reviews by Trijsburg et al., 1992; Anderson,1992; Krupnick et al., 1993) but our model extendswell beyond this framework in order to satisfy thewomen’s needs to deal with profound existentialconcerns. A ‘coping skills’ approach alone is in ourview far too limiting and fails to do justice to theoverall experience of having breast cancer. Wetherefore value the existential approach (Yalom,1980; Mullan, 1992), which emphasises authen-ticity and honest confrontation with such ‘givens’as the finitude of life, freedom to choose andaccepting responsibility for one’s life. But again,to stress the existential dimension without facili-tating adaptive coping would be to short changethe group members.

Some centres have conducted relatively briefprograms — an average of six sessions — thatconcentrate on enhancing coping skills and arepsychoeducational in nature (Telch and Telch,1986; Fawzy et al., 1990; Cunningham et al., 1989,1993); others have reported mixed results(Capone et al., 1980; Bloom et al., 1978; Baider etal., 1984). Our model contrasts considerably withthese; it may be desirable eventually to comparethese treatments. In the meanwhile patient factorsmay call for a range of therapies. Cunningham etal. (1993) for example noted less improvementfrom brief therapy in patients over 50 and in thosewith recurrent disease. We suspect that 20 sessionsover 6 months enables more substantial changethan briefer approaches can accomplish.

The customary therapeutic processes operatingin our groups (Yalom, 1985; Bloch and Crouch,1985) facilitate coverage of a wide range ofthemes central to the members’ experience. Mostof those themes are readily identified and dealtwith by the group. Even a subject as profound asdeath anxiety is confronted without hesitation.On the other hand, a minority of themes,especially sexual difficulties, tend to arise later in

GROUP THERAPY FOR BREAST CANCER PATIENTS 31

the group’s life when a greater sense of trust hasbeen established. Our very first groups werebriefer and there members did struggle to discloseany sexual problems. In those lasting 6 months,members have shared such intensely personalexperiences, albeit with therapist encouragement,gaining much from the realisation that theirsexual difficulties are universal. In this regard, wegenerally view the therapists as proactive, withthe responsibility to ensure that all the themesrelevant to the breast cancer experience(described in detail in our manual) are tackled.Members however still determine to a largeextent when and how the material is covered.

In developing our therapeutic model, we haveadopted the approach pioneered in the NIMHstudy of depression (Elkin et al., 1985), namelypreparing a detailed manual, and then trainingand closely supervising participating therapists.We hope to demonstrate that improved quality oflife can result from participation in group therapybased on a clear set of principles.

CONCLUSION

A cognitive-existential group model has beenintegrated into the clinical care of patients withearly breast cancer, coinciding with other aspectsof medical care.

ACKNOWLEDGEMENT

Thanks are given to Prof David Spiegel for hisencouragement and practical work with our team oftherapists and to Drs Steven Greer, Stirling Mooreyand Maggie Watson for their guidance with adjuvantpsychological therapy with cancer patients.

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