Group-Based Cognitive and Psychosocial Interventions
description
Transcript of Group-Based Cognitive and Psychosocial Interventions
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