GROUP SUPPORT FOR TWO
Group Support for Two:
Support Groups for Pregnant Women With Cancer
Jessie Simmons
Generalist Social Work Practice with Groups SW3052-002
Professor Kinney
University of Cincinnati
April 22, 2016
1
GROUP SUPPORT FOR TWO
Introduction:
“For some women, the happiest time in their lives [is] complicated by the scariest
time in their lives as some pregnant women are diagnosed with cancer” (Cardonick,
2014, p.1). The supported population in this essay is pregnant women of various races,
ethnicities and economic backgrounds who have been diagnosed with cancer, most often
with breast cancer. “Seven to fifteen percent of breast cancer cases occur in pregnant
women making it the most common [type of’] cancer diagnosed during pregnancy”
(Cardonick, 2014, p. 1).
An optimal support group for pregnant women with cancer would be a revolving
membership support group.
Revolving membership groups generally are more structured and require more active leadership than fixed membership groups. Participation and learning are not highly dependent on attendance at previous sessions. In some settings, new members may be brought in at fixed intervals. In a daily group, for instance, new members might enter once a week. Members who have been in the group for a substantial number of meetings often help to orient newer members. (Substance Abuse Treatment: Group Therapy, 2010, p.1).
In an ongoing revolving membership support group, members are allowed to stay as long
as they desire and are only required to go to group sessions where specific topics relevant
to their needs are covered. A typical location for an ongoing revolving membership group
for this population, would be the outpatient section of hospitals, where patients go for
continuing care (Substance Abuse Treatment: Group Therapy, 2010 p. 1).
Pregnant women with cancer face complicated choices that require them to
balance their own need for treatment with the potential effects of treatment on their
unborn child. These women are dealing with the biological changes brought on by each
2
GROUP SUPPORT FOR TWO
stage of pregnancy at the same time they are trying to understand and arrest the spread of
cancer within their bodies. One positive impact of a support group for pregnant women
with cancer would be the comfort of having women around who are coping with the same
medical challenges and fears. One issue that clients in this support group will face is the
fact that their cancer is progressing more quickly than that of non-pregnant women with
cancer (American Cancer Society, 2014, p. 1). A support group for pregnant women with
cancer can assist patients with the decision re: what type of treatment they should pursue.
Treatment type usually depends on the size and location of tumors, the size of the breasts
and the pregnancy trimester of the patient. Support groups for pregnant women usually
connect to the following outside resources: professional counselors for women who are
experiencing depression; doctors including oncologists, obstetricians and pediatricians;
breast care nurses for women who are breast feeding their baby after birth; and online
chatrooms for pregnant women who cannot make it to in person meetings (Cancer
Research UK, n.d. p.1). Support groups for pregnant women work with organizations
including the American Cancer Society, Hope for Two and the Cancer Research Center,
in order to find the resources they need.
Literature Review
Oncologist Elise Cardonick’s article, For Pregnant Women Who Find Out They
Have Cancer, in The Cancer Network Journal does not discuss much about how to form a
support group for pregnant women with cancer. Dr. Cardonick’s article is more of a plea
to health care professionals to spend more time working together for the sake of their two
3
GROUP SUPPORT FOR TWO
patients, rather than acting territorial over who should treat the patient (Cardonick 2014,
p. 1). The article drives home the fact that:
…medical literature currently cannot answer all the relevant questions for the woman facing this cancer or other types during pregnancy. Few oncologists or obstetricians treat more than 2 or 3 patients in this situation in an entire career. The only way to gain the necessary knowledge about cancer found and treated during pregnancy is to gather together experience from various hospitals into one single database (Cardonick, 2014, p. 1).
One might assume that the substance abuse population and pregnant women with
cancer do not have much in common. However, the article Four Group Development
Phase Specific Tasks in Substance Abuse Treatment Methods proves that while the
circumstances of the populations being treated may be vastly different, the support group
process can be applicable to both groups. The article states that all support groups have
the same aims: to survive the turbulent beginning phase; focus on goal accomplishment
and treatment during the middle phase; and establish mental and emotional closure when
an individual leaves the group. The number of pregnant women facing breast cancer is a
slowly growing epidemic, and in order to establish more support groups for this
population, professionals must look to how support groups are run for other populations.
Pregnant women go through many hormonal changes and can experience a vast range of
emotions like those of an addict going through withdrawal. Both populations feel a sense
of isolation because of their circumstances and both populations feel a desire to be around
people who can relate to their circumstances. Pregnant women can look at their lower
survival statistics and give up in the same way that members in drug treatment groups can
be discouraged by the long road ahead and the external odds working against them
4
GROUP SUPPORT FOR TWO
(Anonymous, 2010, p. 1). It can be inspiring to be part of a group where another
member has survived the same situation they are facing.
According to the Cancer Research UK article, Breast Cancer During Pregnancy,
breast cancer in pregnant women is uncommon right now, with only one in three
thousand women experiencing this situation (Cancer Research UK, n.d. p.1). However,
since women are having children later in life, they are now at increased risk of getting
cancer while pregnant. While the majority of pregnant women with cancer are able to
have their babies, some decide to terminate their pregnancy because simultaneously
fighting a life threatening disease while carrying a child is too a heavy burden to carry.
Pregnant women typically receive a later diagnosis, because OBGYNs and general
practitioners are more focused on caring for the pregnancy than diagnosing the woman
for other medical conditions. The article discusses the main treatment for breast cancer,
which is surgery and provides a great deal of insight on what the pregnant cancer patient
could be feeling.
The American Cancer Society’s article, Finding Breast Cancer During Pregnancy,
goes into more detail about how to definitively tell if a woman has breast cancer and
identifying the next steps. Breast biopsies are the best way to know for sure if a woman
has breast cancer. Biopsies are typically outpatient procedures where the area of the
breast is numbed and a needle biopsy is performed to determine if there are any
cancerous cells. If the needle biopsy does not reveal anything, a surgical biopsy must be
done where a small incision is made in the breast to remove and test a piece of tissue.
If breast cancer is found, other tests may be needed to find out if cancer cells have spread within the breast or to other parts of the body. This process is
5
GROUP SUPPORT FOR TWO
called staging. Staging is very important for pregnant women with breast cancer because their cancers tend to be found at a more advanced stage (the tumor is likely to be bigger and to have spread beyond the breast). (American Cancer Society, 2014, p.2).
The American Cancer Society article goes into detail about what will happen during
surgery. A neonatal surgeon often works with the oncologist to determine which stage
during the pregnancy would be the best time to do the surgery and then monitors the
well-being of the fetus during the surgery. Chemotherapy is usually used as an adjuvant
treatment for pregnant women with cancer, after they get a lumpectomy or partial
mastectomy. The article does an excellent job at realistically telling individuals about the
prognosis for pregnant women surviving cancer. In general, pregnant women with breast
cancer are twice as likely to die from breast cancer as other women with breast cancer.
Group Process Selected and Reason for Selecting Process:
The processes described in this section relate to use of a revolving membership
support group model. This model was selected because it allows for flexible entry, exit
and attendance, depending on the member’s needs and health complications. It also
balances teaching structured content with providing an emotionally supportive
environment. Before establishing a group, planning and prescreening must be done.
Prescreening potential members before they enter a group can be helpful because
revolving membership groups usually have limited space of up to fifteen people
(Substance Abuse Treatment: Group Therapy, 2010, p. 1). Social workers may be able to
assist a facilitator with a non-social work background in deciding what personalities
would contribute to group cohesion. Next it is important to prepare potential members
6
GROUP SUPPORT FOR TWO
for what is entailed in joining the group. Clients who have been prepared for treatment
are more likely to stay in the group.
Another potential challenge that should be addressed in the planning phase of this
support group is maximizing retention. The first month that a client attends a group is the
most crucial time, because it is during that period that the client is more likely to drop
out. Reasons for premature termination include stress from outside life; feeling
uncomfortable; inability to share with group facilitator; conflicts about intimacy and
disclosure; and inadequate preparation. Retention rates are affected positively by client
preparation, maximum client involvement during the early stages of treatment, the use of
feedback, prompts to encourage attendance, and the provision of wraparound services
(such as child care and transportation) to make it easier for clients to attend regularly
(Substance Abuse Treatment: Group Therapy, 2010, p. 2).
Another hurdle in the planning phase is establishing a set of agreed upon rules for
the group. “A group agreement establishes the expectations that group members have of
each other, the leader, and the group itself” (Substance Abuse Treatment: Group Therapy,
2010, p. 3). One way to help encourage compliance is for facilitators to ask members to
recall the agreed upon rules at the beginning of every meeting. Some examples of
common group rules are: 1) that attendance is mandatory and if a member cannot make it
they must notify the facilitator twenty-four hours in advance; 2) that members make an
initial three-month commitment; 3) rules regarding touch and physical contact; and
4) confidentiality rules that often state that group members not present should not be
discussed (Substance Abuse Treatment: Group Therapy, 2010, p. 3).
7
GROUP SUPPORT FOR TWO
When members are selected and ground rules are established, the beginning phase
of the group process can commence. During the beginning phase of a support group,
issues arise around topics such as orientation, beginners’ anxiety, and the role of the
leader. “The purpose of the group is articulated, working conditions of the group are
established, members are introduced [and] a positive tone is set for the group” (Substance
Abuse Treatment: Group Therapy, 2010, p. 4). Before cohesion can be established,
introductions must be made. It is important that facilitators and members acknowledge
that each member of the group is in their own phase. In long term revolving membership
groups, it can be hard for new members to find their place, particularly when people are
constantly coming and going (Substance Abuse Treatment: Group Therapy, 2010, p. 4).
One person’s role can be instantly taken over by another after they leave. These changes
can be difficult for veteran members. It is the facilitator’s job to build relationships
between old and new members. This can be particularly important because pregnant
women with breast cancer will be at different stages in their pregnancy, treatment and in
the group process. Some women will be at the beginning of their pregnancy and have just
been diagnosed with cancer; other women will be in the middle to later stages of their
pregnancy and just diagnosed. Since there are so many possibilities, it can create tension
within the group, however the facilitator could work with a social worker to help
participants talk out these budding tensions and create a more supportive environment.
It is inevitable that group members will establish their own social and mental
routines or norms. The facilitator should make sure that the roles and norms being
generated are healthy. When it comes to breaking down harmful routines, social workers
8
GROUP SUPPORT FOR TWO
may have an advantage because members may look to them as professional role models
(Substance Abuse Treatment: Group Therapy, 2010, p. 5). It may prove more challenging
for a non-social worker to break down harmful social norms if they are a part of the target
population. They may feel an allegiance with the members, not want members to feel
betrayed and, as a result, may overlook harmful routines. An example of a harmful norm
would be the formation of cliques within the group. This can happen in revolving long
term membership groups because veteran members may seek to cling to each other.
Another surprisingly unhelpful norm occurs when the facilitator and members have such
a close bond that they are unwilling to criticize or advise other members (Substance
Abuse Treatment: Group Therapy, 2010, p. 5). Group cohesion is established by the
healthy push and pull of nurture and conflict. It is through nurture and conflict that group
work, discussion and goals can be accomplished. If participants survive the turbulent
beginning phase of becoming a part of a support group, it is likely that they will stick
with the group, because the hardest part is establishing cohesion and a sense of
connection and trust.
It is during the middle phase that a support group accomplishes most of the
therapy and work. “During this phase, the leader balances content, which is the
information and feelings overtly expressed in the group, and process, which is how
members interact in the group” (Substance Abuse Treatment: Group Therapy, 2010, p. 5).
One of the main mistakes new group facilitators make is focusing just on the content.
Many people attend support groups because they want a space to voice their feelings and
opinions, therefore facilitators need to find a way to balance process and expression. For
9
GROUP SUPPORT FOR TWO
pregnant women with cancer, there will be a lot of anxiety, excitement and sadness and
many may be attending the group for the sole purpose of discussing their feelings and
meeting other women who feel the same way. It is important that support groups for
pregnant women with cancer make an extra effort to provide a nurturing environment for
these women.
The final phase of the group process is the end phase. “Termination is a
particularly important opportunity for members to honor the work they have done, to
grieve the loss of associations and friendships, and to look forward to a positive future”
(Substance Abuse Treatment: Group Therapy, 2010, p. 6). Termination occurs at
different points for different people. Sometimes members can resent the fact that another
group member has reached the point where they want to move on. The process of
leaving a group is a time for members to: discuss their feelings about leaving; share their
plans for moving forward; and reflect upon the impact their fellow members made on
them (Substance Abuse Treatment: Group Therapy, 2010, p. 6). According to Hope for
Two, a support group for pregnant women with breast cancer, members are allowed to
attend meetings and receive therapeutic services and doctors’ appointments for up to five
years during their remission (Hope for Two, 1997, p. 4).
Methods of Best Practice
A best practice that can be used in the prescreening phase is asking analytical
questions to help determine if a potential member will be an appropriate asset to the
group. Some suggested prescreening questions include: What do you think you can
contribute to this group? How do you think you would feel in a group in which your
10
GROUP SUPPORT FOR TWO
opinion differs from other members? How would you cope with another member in the
group who believes in a higher power when you do not? (Substance Abuse Treatment:
Group Therapy, 2010, p. 1). Asking a set of prescreening questions and analyzing
responses can help a facilitator visualize how the candidate would fit in with the other
members. Facilitators should also conduct prescreening interviews, because they allow
the patient and facilitator to form a therapeutic alliance, to reach consensus on what is to
be accomplished, to educate the client about group therapy, to allay anxiety related to
joining a group and to “explain the group agreement” (Substance Abuse Treatment:
Group Therapy, 2010, p. 1).
To help individuals prepare to become members of the group, it is suggested that
facilitators utilize role induction strategies. One role induction technique, vicarious
training, utilizes lectures, films, and interviews to teach clients how to set achievable
goals for group therapy and about expected behaviors (Substance Abuse Treatment:
Group Therapy, 2010, p. 2). Vicarious training can be done through roleplaying among
the facilitators, so that members can witness what appropriate behaviors look like. A
second best practice technique is motivational interviewing. This listening technique uses
specific questions to help clients realize the benefits of making changing in their lives
(Substance Abuse Treatment: Group Therapy, 2010, p. 2). Other best practices that could
be utilized include follow up appointment reminder phone calls; appointment cards with
the date of the next of the meeting; and provision of wraparound services such as
transportation and childcare.
11
GROUP SUPPORT FOR TWO
A best practice technique for creating cohesion among group members in the
beginning phase is creating a supportive environment. One way that the facilitator can
help develop a supportive environment is by utilizing group bonding activities. Ideally,
group-bonding activities will focus on similarities between the members. For example,
the round robin technique of group communication can give group members the chance
to express their feelings. Asking other members to react to what another member has just
shared can also help form connections among members (Substance Abuse Treatment:
Group Therapy, 2010, p. 6). If the facilitator does not have a social work background and
is not used to creating bonding activities, social workers can serve as consultants for
facilitators.
Ethical Concerns, Cultural Diversity and Influences
Social workers who are facilitators of support groups or are working with support
groups on a consultation basis are not supposed to become friends with their clients
(Substance Abuse Treatment: Group Therapy, 2010, p. 3). Social workers can maintain
positive, productive and supportive working relationships with clients without becoming
their friend or social media buddy. The job of the social worker is to be a positive,
professional mentor and guide. The role of a non-social work facilitator, who could be a
breast cancer survivor, may be different however, because they are not bound by a code
of ethics and they have been through experiences similar to those of other group
members.
One of the biggest ethical concerns in working with pregnant women with breast
cancer is supporting them whether they chose to terminate or go through with their
12
GROUP SUPPORT FOR TWO
pregnancy. Some women decide that going through the stress of cancer treatment is all
that they can handle without having to worry about how it will affect their baby. For
women who do decide to keep their baby, it is imperative that the facilitator and group
members help guide the mother-to-be in her decision about what treatment route she
should chose. The social worker must make sure that the client does not receive radiation
therapy because it can cause birth defects or cancer in the baby (Cancer Research UK,
n.d. p.1.). Furthermore, the social worker should caution a pregnant woman with breast
cancer that chemotherapy, given during the first trimester, can cause a miscarriage
because the fetus is just beginning to develop (Cancer Research UK, n.d. p.1.). It is vital
that a specialist “examine the baby [because many] women worry about the effect of the
breast cancer on the baby. [In addition] A pathologist will examine the placenta because,
although very rare, it is possible for cancer cells to spread there” (Cancer Research UK,
n.d. p.1.).
Conclusion/Summary
Pregnant women with breast cancer are a small population. However, they are
slowly growing and our healthcare system is still learning how to support these women.
Support groups for pregnant women with breast cancer are few and far between, but it is
important to study other support groups as a template for how establish more competent
and comforting support groups for this population. Social workers cannot let their own
personal beliefs influence the way they advise these women during a very vulnerable and
confusing time of their lives. Furthermore, it is extremely important that support groups
for pregnant women with cancer create a supportive, welcoming and inclusive
13
GROUP SUPPORT FOR TWO
environment, which is often challenging for long-term revolving membership groups. For
some group members, termination of membership in this support group means death and
that is a very difficult concept for facilitators and members to endure. Thankfully, there
are activities that facilitators can introduce to help break down emotional barriers. It can
be hard to let new members in emotionally, while grieving the loss of another member.
But maintaining a welcoming environment can shine a bright light on a very difficult and
turbulent chapter in lives of pregnant women diagnosed with cancer.
14
GROUP SUPPORT FOR TWO
References
American Cancer Society. (2014). Finding Breast Cancer During Pregnancy. Cancer Network
Journal, 1-7. Retrieved April 15, 2016.
Breast Cancer During Pregnancy. (n.d.). Cancer Research UK, 113(1), 1st ser., 1-15.
Cardonic, E. (2014). For Pregnant Women Who Find Out They Have Breast Cancer. Cancer
Network Journal, 1-20. Retrieved April 14, 2016.
Four Group Development Phase Specific Tasks. (2010). Substance Abuse Treatment
Methods, 4(6), 6th ser., 1-22. Retrieved April 14, 2016.
Hope For Two. (1997, October 1). Retrieved April 14, 2016, from http://www.hopefortwo.org/
15
Top Related