Group-Based Cognitive and Psychosocial Interventions

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Group-Based Cognitive and Psychosocial
Interventions

• Rhonda M. Williams, PhD.
• MS Center of Excellence West
• VA Puget Sound
• University of Washington

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Outline

• Rationale for group-based therapy
• Foundations of group-based therapy
• Cognitive rehabilitation considerations
• Unique needs of veterans and persons with MS
• Translating Cognitive Rehabilitation Strategies
  and Group Psychotherapy principals into practice
  the VAPSHCS experience

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Psychological Needs of Person with MS
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All groups are not created equal

• Support Groups
• Self-help groups
• Psychotherapy groups
• Structured skills groups
• Informal Peer Support
• In person vs. telephone vs. on-line

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Why work with groups?

• (Potentially) Efficacious
• Mixed results from peer-led self-help groups
• Generally good results from professionally-led
  groups
• Cost effective
• Unique therapeutic benefits
• Tailored content (by diagnostic group)

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Group Therapy Efficacy

• Meta-analysis 111 experimental or
  quasi-experimental studies
• Groups meet regularly with identified leader,
  purpose
• 24 studies were groups based on medical
  diagnosis
• Burlingame, Fuhriman, Mosier, 2003, Group
  Dynamics Theory, Research Practice

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Meta-analysis results

• Pre-Post Treatment, overall ES .71
• Average group therapy more effective than
  wait-list control (ES .47-.63)
• Homogenous groups gt heterogeneous groups (.56 vs
  .25)
• Outpatient gt inpatient
• Mixed gender gt only one gender

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Group Therapy Efficacy

• Generally good support for professionally led,
  skills-based interventions
• Peer-led support groups that focus on both
  education and emotional support may be more
  effective than those that provide only emotional
  support
• Individual differences e.g., Breast Cancer
  literature peer discussion groups helpful for
  women without good partner support, but harmful
  for women with good partner support
• Helgeson Cohen 1996 Health Psychology
• Helgeson, Cohen, Shultz Yako, 2000, Health
  Psychology

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Modality, Leader influence on Tx of Depression
 

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

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Efficacy of Groups for Persons with MS

• 2-year RCT coping skills group (CSG) vs. peer
  telephone support (PTS)
• CSG improvement in psychosocial role
  performance, coping, family spiritual
  satisfaction, personal growth, social
  relatedness, self-acceptance
• PTS most developed a realistic, but negative
  appraisal of abilities and reduced self-efficacy
  
• Persons with existing affective problems
  benefitted more from PTS
• Schwartz 1999, Health Psychology, 18 (3).

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Why (efficacious) groups are efficacious

• Covers different material (more skills)
• Unique therapeutic factors
• Less stigmatized, natural extension of medical
  education
• Formalization of social support (more carry over
  opportunities)

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Group vs. Individual Therapy Topics

• Groups
• Scientifically validated, predetermined
• Enhancing social support
• Active coping
• Emotional Expression
• Reprioritizing

• Individual
• Patients personal concerns
• Personal relationship problems
• Functional changes, losses

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

• Altruism
• Opportunity to give to one another
• Antidote to self-absorption
• Imitative Behavior and Role Modeling
• Powerful form of learning

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Therapeutic Factors in Group Therapy Continued
(Yalom, 1986)

• Imparting Information
• Understanding a phenomenon is the first step to
  controlling it/coping
• Sharing information is seen as a gift, conveys
  caring and mutual interest
• Instillation of Hope
• faith in treatment and high expectation is
  correlated with positive therapy outcome
• continual access to role models for improvement

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• Patients in the same group
• may benefit from
• different combinations of
• therapeutic factors.
• I.Yalom, (1986). The Theory and Practice of Group
  Psychotherapy, 3rd Edition

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Special Considerations for Cognitively Impaired
Groups

• Facilitating communication
• Managing attention deficits
• Managing executive function impairment
• Facilitating memory and retention
• Regulating affect, managing behavior
• Interface between mood, psychopathology, and
  cognition

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Foundation of Cognitive Rehabilitation

• Cannot isolate cognition. Brain damage affects
  cognitive, social, behaivoral, and emotional
  functioning.
• Goal oriented, problem-focused, builds on
  strengths.
• Treatment is structured.
• Sohlberg Mateer, 2001, Cognitive Rehabilitation

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Considerations in Group Planning

• Participants how much variability?
• Group goals skills-based or process oriented
• Logistics open/closed, location, times, duration
• Leader Qualifications mental health
  professional? Personal experience with particular
  illness? Charisma?

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Unique group needs for persons with MS

• Persons with MS more likely than persons with any
  other disease to seek help on-line (Davison,
  Pennebaker, Dickerson, 2000. American
  Psychologist)
• Compared to persons with other illnesses, persons
  with MS are least likely to be satisfied with
  their group experiences, perceiving less
  organization and less capable leadership Maton
  KI. 1988, Am J of Community Psychology

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Veteran Identified needs

• Highly variable experiences with community based
  support groups
• Very positive experiences with other structured
  VA groups
• Diversity of cognitive and other limitations
• Caregiver support and education (50 of veterans
  in Northwest USA received all of their MS-related
  care from their unpaid spouse)

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VA Puget Sound Groups

• Tailored for veterans
• Older (mean age in VISN 20 is 55 years)
• more likely to be male (86)
• more disabled
• lower mean income than the general population
  (Vollmer, Hadjimichael, Preiningerova, Weija,
  Buenconsejo, 2002).

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Recommended Group Components

• a formal screening process, closed format
• emphasis on coping, positive strategies
• professional leader(s)
• structured material tailored for individuals
  with a wide range of cognitive and communication
  abilities
• to increase homogeneity, offer different groups
  each with a particular focus

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Practical Tips for Groups with Cognitively
Impaired Participants

• Repetition
• Routine (day, time, location)
• Minimal didactics
• Multiple learning modalities
• Structured activities
• Folders and color-coded handouts
• Cues memory aids incorporated (e.g., nametags)

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Puget Sound Groups

• Living Well with MS
• Caregiver Support
• Cognitive Behavioral Therapy for Depression
• Enhancing Cognitive Skills
• Improving Interpersonal Relationships and
  Managing Mood

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Acknowledgments Group Development Leadership

• VAPSHCS Speech Pathologists Kent Yockey Raelene
  Buelena
• VAPSHCS Social Workers Tara Stablein Jan
  Buchanan
• Aaron Turner, PhD
• Psychology Interns Chu, Caples, Ketz, Hanley,
  Mulick, Hartzler, Campbell, Balsam, Raichle