Group-Based Cognitive and Psychosocial

InterventionsRhonda M. Williams, PhD.Rhonda M. Williams, PhD.

MS Center of Excellence WestMS Center of Excellence WestVA Puget SoundVA Puget Sound

University of WashingtonUniversity of Washington

Outline Rationale for group-based therapyRationale for group-based therapy Foundations of group-based therapyFoundations of group-based therapy Cognitive rehabilitation considerationsCognitive rehabilitation considerations Unique needs of veterans and persons Unique needs of veterans and persons

with MSwith MS Translating Cognitive Rehabilitation Translating Cognitive Rehabilitation

Strategies and Group Psychotherapy Strategies and Group Psychotherapy principals into practice– the VAPSHCS principals into practice– the VAPSHCS experienceexperience

Psychological Needs of Person with MS

IndividualPsychotherap

y

Medical Treatment & Education,

Skills Training

Peer Support

IndividualPsychotherapy

Medical Treatment & Education,

Skills Training

Peer Support

Group Psychotherapy

All groups are not created equal Support GroupsSupport Groups Self-help groupsSelf-help groups Psychotherapy groupsPsychotherapy groups Structured skills groupsStructured skills groups Informal Peer SupportInformal Peer Support In person vs. telephone vs. on-lineIn person vs. telephone vs. on-line

Why work with groups? (Potentially) Efficacious:(Potentially) Efficacious:

Mixed results from peer-led self-help Mixed results from peer-led self-help groupsgroups

Generally good results from Generally good results from professionally-led groupsprofessionally-led groups

Cost effectiveCost effective Unique therapeutic benefitsUnique therapeutic benefits Tailored content (by diagnostic group)Tailored content (by diagnostic group)

Group Therapy Efficacy Meta-analysis: 111 experimental or Meta-analysis: 111 experimental or

quasi-experimental studiesquasi-experimental studies Groups meet regularly with Groups meet regularly with

identified leader, purposeidentified leader, purpose 24% studies were groups based on 24% studies were groups based on

medical diagnosismedical diagnosis Burlingame, Fuhriman, & Mosier, 2003, Group Dynamics: Burlingame, Fuhriman, & Mosier, 2003, Group Dynamics:

Theory, Research & PracticeTheory, Research & Practice

Meta-analysis results Pre-Post Treatment, overall ES = .71Pre-Post Treatment, overall ES = .71 Average group therapy more effective Average group therapy more effective

than wait-list control (ES .47-.63)than wait-list control (ES .47-.63) Homogenous groups > Homogenous groups >

heterogeneous groups (.56 vs .25)heterogeneous groups (.56 vs .25) Outpatient > inpatientOutpatient > inpatient Mixed gender > only one genderMixed gender > only one gender

Group Therapy Efficacy Generally good support for professionally led, Generally good support for professionally led,

skills-based interventionsskills-based interventions Peer-led support groups that focus on both Peer-led support groups that focus on both

education and emotional support may be more education and emotional support may be more effective than those that provide only effective than those that provide only emotional support emotional support

Individual differences: e.g., Breast Cancer Individual differences: e.g., Breast Cancer literature: peer discussion groups helpful for literature: peer discussion groups helpful for women without good partner support, but women without good partner support, but harmful for women with good partner support harmful for women with good partner support

Helgeson & Cohen 1996Helgeson & Cohen 1996: : Health PsychologyHealth Psychology Helgeson, Cohen, Shultz & Yako, 2000, Health PsychologyHelgeson, Cohen, Shultz & Yako, 2000, Health Psychology

Modality, Leader influence on Tx of Depression

 

   

Cognitive Behavioral Therapy

Mutual Support Group

Professional Leader

Paraprofessional Leader

21% Depression alleviated (N=19)

46% Depression alleviated (N=22)

  

58% Depression Alleviated (N=22)

 29% Depression

alleviated(N=29)

 

    

 

All groups reduced depression symptoms. Adherence to manual associated with greater improvement.Bright, Baker, Neimeyer (1999). JCCP 67(4)

Efficacy of Groups for Persons with MS 2-year RCT : coping skills group (CSG) vs. peer 2-year RCT : coping skills group (CSG) vs. peer

telephone support (PTS)telephone support (PTS) CSG: improvement in psychosocial role CSG: improvement in psychosocial role

performance, coping, family & spiritual performance, coping, family & spiritual satisfaction, personal growth, social satisfaction, personal growth, social relatedness, self-acceptance relatedness, self-acceptance

PTS: most developed a “realistic, but negative PTS: most developed a “realistic, but negative appraisal of abilities” and reduced self-efficacy appraisal of abilities” and reduced self-efficacy

Persons with existing affective problems Persons with existing affective problems benefitted more from PTS benefitted more from PTS

Schwartz 1999, Health Psychology, 18 (3).Schwartz 1999, Health Psychology, 18 (3).

Why (efficacious) groups are efficacious Covers different material (more Covers different material (more

skills)skills) Unique therapeutic factors Unique therapeutic factors Less stigmatized, natural extension Less stigmatized, natural extension

of medical educationof medical education Formalization of social support Formalization of social support

(more carry over opportunities)(more carry over opportunities)

Group vs. Individual Therapy Topics

GroupsGroups Scientifically Scientifically

validated, validated, predeterminedpredetermined

Enhancing social Enhancing social support support

Active copingActive coping Emotional ExpressionEmotional Expression ReprioritizingReprioritizing

IndividualIndividual Patient’s personal Patient’s personal

concernsconcerns Personal Personal

relationship relationship problemsproblems

Functional Functional changes, losseschanges, losses

Therapeutic Factors in Group Therapy Cont. (Yalom, 1986)

AltruismAltruism Opportunity to give to one anotherOpportunity to give to one another Antidote to self-absorptionAntidote to self-absorption

Imitative Behavior and Role Imitative Behavior and Role

ModelingModeling Powerful form of learningPowerful form of learning

Therapeutic Factors in Group Therapy Continued

(Yalom, 1986) Imparting InformationImparting Information Understanding a phenomenon is the first Understanding a phenomenon is the first

step to controlling it/copingstep to controlling it/coping Sharing information is seen as a gift, Sharing information is seen as a gift,

conveys caring and mutual interestconveys caring and mutual interest Instillation of HopeInstillation of Hope

faith in treatment and high expectation is faith in treatment and high expectation is correlated with positive therapy outcomecorrelated with positive therapy outcome

continual access to role models for continual access to role models for improvementimprovement

Patients in the same group Patients in the same group may benefit from may benefit from

different combinations of different combinations of therapeutic factors.therapeutic factors.

I.Yalom, (1986). The Theory and Practice of I.Yalom, (1986). The Theory and Practice of Group Psychotherapy, 3Group Psychotherapy, 3rdrd Edition Edition

Special Considerations for Cognitively Impaired Groups Facilitating communication Facilitating communication Managing attention deficitsManaging attention deficits Managing executive function Managing executive function

impairmentimpairment Facilitating memory and retentionFacilitating memory and retention Regulating affect, managing behaviorRegulating affect, managing behavior Interface between mood, Interface between mood,

psychopathology, and cognitionpsychopathology, and cognition

Foundation of Cognitive Rehabilitation Cannot isolate cognition. Brain damage Cannot isolate cognition. Brain damage

affects cognitive, social, behaivoral, and affects cognitive, social, behaivoral, and emotional functioning.emotional functioning.

Goal oriented, problem-focused, builds Goal oriented, problem-focused, builds on strengths.on strengths.

Treatment is structured.Treatment is structured.

Sohlberg & Mateer, 2001, Sohlberg & Mateer, 2001, Cognitive Cognitive RehabilitationRehabilitation

Considerations in Group Planning Participants: how much variability?Participants: how much variability? Group goals: skills-based or process Group goals: skills-based or process

orientedoriented Logistics: open/closed, location, Logistics: open/closed, location,

times, durationtimes, duration Leader Qualifications: mental health Leader Qualifications: mental health

professional? Personal experience professional? Personal experience with particular illness? Charisma?with particular illness? Charisma?

Unique group needs for persons with MS Persons with MS more likely than persons Persons with MS more likely than persons

with any other disease to seek help on-with any other disease to seek help on-line line (Davison, Pennebaker, & Dickerson, 2000. American (Davison, Pennebaker, & Dickerson, 2000. American Psychologist) Psychologist)

Compared to persons with other illnesses, Compared to persons with other illnesses, persons with MS are least likely to be persons with MS are least likely to be satisfied with their group experiences, satisfied with their group experiences, perceiving less organization and less perceiving less organization and less capable leadership capable leadership Maton KI. 1988, Am J of Maton KI. 1988, Am J of Community PsychologyCommunity Psychology

Veteran Identified needs Highly variable experiences with Highly variable experiences with

community based support groupscommunity based support groups Very positive experiences with other Very positive experiences with other

structured VA groupsstructured VA groups Diversity of cognitive and other Diversity of cognitive and other

limitationslimitations Caregiver support and education (50% of Caregiver support and education (50% of

veterans in Northwest USA received all of veterans in Northwest USA received all of their MS-related care from their unpaid their MS-related care from their unpaid spouse)spouse)

VA Puget Sound Groups Tailored for veterans Tailored for veterans Older (mean age in VISN 20 is 55 Older (mean age in VISN 20 is 55

years)years) more likely to be male (86%)more likely to be male (86%) more disabledmore disabled lower mean income than the lower mean income than the

general populationgeneral population (Vollmer, Hadjimichael, (Vollmer, Hadjimichael, Preiningerova, Weija, & Buenconsejo, 2002). Preiningerova, Weija, & Buenconsejo, 2002).

Recommended Group Components a formal screening process, closed a formal screening process, closed

format format emphasis on coping, positive strategiesemphasis on coping, positive strategies professional leader(s) professional leader(s) structured material tailored for structured material tailored for

individuals with a wide range of cognitive individuals with a wide range of cognitive and communication abilities and communication abilities

to increase homogeneity, offer different to increase homogeneity, offer different groups each with a particular focus groups each with a particular focus

Practical Tips for Groups with Cognitively Impaired Participants Repetition Repetition Routine (day, time, location)Routine (day, time, location) Minimal didacticsMinimal didactics Multiple learning modalitiesMultiple learning modalities Structured activitiesStructured activities Folders and color-coded handoutsFolders and color-coded handouts Cues & memory aids incorporated (e.g., Cues & memory aids incorporated (e.g.,

nametags)nametags)

Puget Sound Groups Living Well with MSLiving Well with MS Caregiver Support Caregiver Support Cognitive Behavioral Therapy for Cognitive Behavioral Therapy for

DepressionDepression Enhancing Cognitive Skills Enhancing Cognitive Skills Improving Interpersonal Improving Interpersonal

Relationships and Managing MoodRelationships and Managing Mood

Acknowledgments: Group Development & Leadership VAPSHCS Speech Pathologists Kent VAPSHCS Speech Pathologists Kent

Yockey & Raelene BuelenaYockey & Raelene Buelena VAPSHCS Social Workers Tara VAPSHCS Social Workers Tara

Stablein & Jan BuchananStablein & Jan Buchanan Aaron Turner, PhDAaron Turner, PhD Psychology Interns: Chu, Caples, Psychology Interns: Chu, Caples,

Ketz, Hanley, Mulick, Hartzler, Ketz, Hanley, Mulick, Hartzler, Campbell, Balsam, RaichleCampbell, Balsam, Raichle