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Group process expectations and outcome with post-myocardial infarction patients
Group Process Expectations and Outcome with Post-Myocardial Infarction Patients Melvin J. Stern, M.D. Associate Clinical Professor
of Psychiatry
Elizabeth Plionis, DSW Research Associate
Leanne Kaslow, MSW Research Associate,
George Washington
University,
Abstract: Post-myocardial infarction patients participating
Washington,
in
a 12-session group therapy program completed self-rating measures ranking group process variables before and after therapy. Learning positive qualities, experimenting with new behavior, receiving advice and guidance,and gaining cognitive insight by learning how their lifestyle plays a role in the development and management of their coronary condition were most valued. Interpersonal learning, catharsis, and testing group acceptance by revealing embarrassing things about oneself were ranked lowest. These results are examined in the context of previous descriptions of coronary patients’ behavior in therapy.
Group therapy with medically ill patients has a long history in modern psychiatry. The pioneer work was done by Pratt (1) who, in 1907, described what he referred to as the class method for treating tuberculous patients. His technique was to tell patients about their disease, encourage them to suppress worrisome thoughts and wishes, and inspire them to find an interest in life. Pratt subsequently applied his method to treating diabetic and cardiac patients (2). Others have since used group methods in treating patients with a variety of medical syndromes, including hypertension (3), myocardial infarction (4,5), Parkinsonism (6), multiple sclerosis (7), asthma (8), chronic lung disease (9), and metastatic cancer (10). Post-transplant (ll), ileostomy (12),
Supported in part by grant no. G008003044 from the National Institute of Handicapped Research, Department of Education, Washington, D.C.
General Hospital Psychiatry 6, 101-108, 1984 0 Elsevie Science Publishing Co., Inc. i984 52 Vanderbilt Avenue, New York, NY 10017
D.C.
and terminally ill (13) patients have also participated in group therapy. All of the medical groups have shared certain characteristics. They have tended to be homogeneous in composition (based on commonality of illness or symptomatology) and short term (20 sessions or fewer). They have stressed education about the illness in question and support for group members in coping with the effects of their illness, both on an individual basis and in relation to family members, peers, and work colleagues. Group sessions have been described as being suffused with a clublike atmosphere, with members working to help one another solve problems of daily life, particularly in relation to the illness that brought them to the group. At times, however, the group gestalt has been reported to shift to that of a classroom, where education on the disease process and compliance with the medical regimen have been the major goals. More rarely, the medical group has functioned similarly to a psychodynamic group in working to resolve intrapsychic and interpersonal conflicts. The purpose of this study was to begin to define in a more rigorous way those group process variables that medical patients consider important in making use of group therapy. Such information could facilitate the development of a schematic model of group therapy that might address the needs of medically ill patients in a more effective manner. 101 ISSN 0163-8343B4Kl.00
M. J. Stern
Method Thirty-five post-myocardial infarction patients were randomly assigned to a 12-session group counseling program as part of a larger controlled study comparing the relative rehabilitation efforts of group counseling with a graduated exercise training program. The subjects were men and women between 30 and 69 years of age who had a documented myocardial infarction not less than six weeks or more than one year prior to admission to the study. They had either impaired exercise tolerance (seven METS or less for men and six METS or less for women) or anxiety/depression (a raw score of at least 19 on the Taylor Manifest Anxiety Scale and at least 40 on the Zung Self-Rating Depression Scale) at the time of the screening; were willing to be randomized and were able to participate fully in all evaluations and treatment sessions for the length of the study; had no medical or emotional conditions (specified) that would preclude participation in any part of the study; and were not participating in another counseling or graduated exercise training program. After being admitted to the study, patients were randomized in blocks of six to either a group counseling, exercise, or control group. Assignment to group counseling entailed participation in a series of 12 weekly 60-minute sessions led by an experienced group therapist (M.S.), a social worker, and at times a nurse clinician. The goals of the group were to 1) improve the patient’s understanding of his/her illness as well as offer help with specific problems that might arise eg, work, family, diet; 2) provide a forum for ventilation and expression of feelings, improve interpersonal communication and reduce the sense of isolation each member might feel without group support; 3) develop an awareness of pre-illness behavior patterns that may have contributed to the illness, eg, type A behavior; 4) enhance ego strengths and reduce reliance on unhealthy defense mechanisms such as hypochondriasis and depression; and 5) provide positive techniques to help patients with chronic free-floating anxiety through deep muscle relaxation exercises. The first therapy group was conducted in an open-ended manner. In the opening session members introduced themselves to one another by providing accounts of their heart attack and subsequent convalescence. The group leader provided an overall perspective on problems encountered in the post-myocardial infarction period, acquainted the 102
members with the basic principles of group participation, and encouraged them to talk freely about any topic they wished. In subsequent sessions the members discussed many areas of stress in their lives. However, the sessions bore little relationship to one another, had no sense of continuity, and were frequently interrupted by questions indicating the group members’ lack of understanding of the pathophysiology of heart attacks and indications for medication and/or certain procedures such as catheterization. These questions would frequently disrupt the group process as members switched from members of a work-oriented group to being dependent on the leaders for information. To remedy this situation, beginning with the second 12-session group, we altered the group format so that the more structured education and behavioral methodology, supplemented by reading material and relaxation exercises, was provided in the initial five sessions. The remaining sessions were set aside for more process-oriented work. This change produced the desired effect. Members were less distracted by lack of knowledge of their coronary condition and devoted most of their time and effort in group to tackling troublesome life problems. Discussion focused upon issues such as stress at work (coping with feelings of insecurity over holding onto one’s job, obtaining promotions and/or not being treated by others as being over the hill versus concerns about not getting too worked up at conferences, or fears about working overly long hours), at home (particularly applicable to women who tended to feel overprotected, frequently against their better judgment), socially (countering a tendency towards withdrawal and isolation), sexually (worrying whether resumption of sex would lead to a recurrent infarction), physically (worries over another infarction, invalidism and/or death, particularly when experiencing complications such as angina, arrhythmias, and shortness of breath), and/or in relation to the need to diet, discontinue smoking, or increase physical activity levels. In the final session members participated in a summary discussion and general critique of work done in the group and completed questionnaires designed to assess their impressions of the group process.
Evaluation Instruments Two methods of evaluating the saliency of the group process were used. The first, a rank order questionnaire developed by Lieberman (14) to as-
PostmyocardialInfarction Patients
sess the relative importance of 11 group process items, was administered before the start of counseling and at the beginning of the last counseling session. This instrument assessed change (if any) in patient perception of the relative importance of the group process items over the 12-week period of counseling. A second evaluation measure, a modified version of Yalom’s Curative Factors in Group Therapy Q-Sort (15), was administered only at the beginning of the last group counseling session. The Q-Sort adds to the information obtained from the Lieberman questionnaire in that it is more comprehensive and provides an in-depth view of the patient’s assessments of those items which were of benefit during the group therapy sessions. Yalom’s Q-Sort consists of 11 curative factors: altruism, group cohesiveness, universality, guidance, catharsis, selfunderstanding, instillation of hope, existential factors, interpersonal learning, identification, and family re-enactment. We modified the Q-Sort by eliminating the identification and family re-enactment factors (because these factors were judged to be more suitable for a younger population); by reducing the descriptive items subsumed under each factor from five to three, thereby making the instrument more concise and able to be completed in a shorter period of time (approximately 20 minutes); and, wherever necessary, by changing the item
Table 1. Sociodemographic characteristics No.
Characteristic Sex
31 4
Male Female Race White Black Age 48 49-58 259 Social classa 1 2-3 4-5 Marital status Married Other ‘Hollingshead
Two-Factor
28 7 9 12 14 8 19 8 30 5 Index.
wording so that each item had relevance for a coronary patient population, ie, under “guidance” we inserted the descriptive item “learning about coronary disease and its management” (see appendix).
Results Table 1 provides a sociodemographic profile of the 35 patients randomized into group counseling. They are predominantly white, married, middle to upper middle class males with a mean age of 54.7 years. Twenty-two patients (63%) began participating in the study within six months of their heart attack. Fourteen patients (40%) reported having at least one counseling session with an outside mental health professional prior to entering the study. Of these, three patients had had between two and five counseling sessions and five patients had had six sessions to over a year’s therapy.
Attendance Twenty-six patients (74%) attended more than three-quarters of the sessions. Five patients (15%) attended between half and three-quarters of the sessions and four (11%) dropped out within the first three sessions. The only sociodemographic differences between the four dropouts and the remainder of the patients was that all were male and two were black. No differences were noted between the five patients attending one-half to threequarters of the sessions and the remainder of the patients.
Lieberman Group Process Expectations Questionnaire Table 2 lists group members’ ranking of Lieberman Questionnaire items before beginning therapy. On this questionnaire, the numerical score is inversely related to rank; the higher the score, the lower the ranking. The lowest cumulative score possible, if all subjects completing the questionnaire were to rank an item as number one, is 29, and the highest possible score is 319. The cardiac patients ranked learning positive qualities highest. Getting insight from the past, experimenting with new behavior, and receiving advice followed next. These four items rounded out the most important expectations. Being confronted and challenged, being supported and valued, seeing undesirable things about oneself, and experiencing excitement and joy occupied a middle position. Revealing secrets, experi103
M. J. Stern
Table 2. Group process expectation
Item Learn positive qualities Get insight from past Experiment with new behavior Receive advice Be confronted and challenged Be supported and valued See undesirable things Experience job and excitement Reveal secrets Experience negative feelings
Become anxious and depressed
rankings before group counseling
Group 1 (N = 5) 1
314 314 5 6 2 718 718 9 10 11
Group 2 (N = 6)
Group 3 (N = 5)
1
1
2 3 4 6 5 8 7 9 10 11
2 5 3 4 6 7 8 9 10 11
encing negative feelings, and becoming anxious and depressed occupied the least desirable level. The last item, becoming anxious and depressed, came close to achieving a perfect negative score. As Table 2 shows, there is some intergroup variation in ranking. In general, the four highest items remain most desirable for at least two-thirds of the groups, and the three least desirable items remain so for almost all groups. Following completion of group counseling, the same 29 members rated the group experience (Table 3). Ranking remained essentially unchanged. One exception was that receiving advice moved to third position and experimenting with new behavior moved to fourth. There also appeared to be a stronger clustering of the first three items, learning positive qualities, getting insight from the past, and receiving advice; experimenting
Group 4 (N = 4)
Group 5 (N = 5)
3 4 7 2 6 1 5 8 11 9 10
4 6 1 5 3 9 7 2 10 8 11
Group 6 (N = 4)
5 l/2 l/2 4 6 7 3 10 9 8 11
Cumulative score (N = 29)
Rank
86 111 119 123 151 167 173 180 256 256 294
1 2 3 4 5 6 7 8 9110 9110 11
with new behavior (previously in the first category) moved closer to the secondary values of being confronted and challenged and being supported and valued. These are clearly very minor alterations considering the multiple possible combinationsand permutations. As with the pregroup ranking, there is some intergroup variation in the postgroup assessment. However, the difference in ranking is even less for the postgroup assessment. Five-sixths of the groups rated the first three items highest and, with one exception, all rated the last three items lowest.
Yalom Q-Sort Table 4 presents a rank ordering of the nine selected Yalom Q-Sort factors. The highest score is correlated with the most valued rank. The highest possi-
Table 3. Group process expectation rankings after group counseling
Item Learn positive qualities Get insight from the past Receive advice Experiment with new behavior Be confronted and challenged Be supported and valued See undesirable things Experience joy and excitement Reveal secrets Experience negative feelings Become anxious and depressed
104
Group 1 (N = 5)
Group 2 (N = 6)
Group 3 (N = 5)
3 2 1 5 7 4 8 6 9 10
2 1 4 3 6 5 8 7 9 10 11
2 3 7 5 6 4 8 9 10 11
11
1
Group 4 (N = 5) 1
2 3 4 5 7 6 9 11 10 8
Group 5 (N = 5)
Group 6 (N = 4)
Cumulative score (N = 29)
Rank
6 415 1 2 415 8 3 7 9 11 10
1 2 3 5 8 4 7 6 9 10 11
90 91 102 137 160 165 181 200 271 280 296
1 2 3 4 5 6 7 8 9 10 11
Postmyocardial Infarction Patients
Table 4. Yalom Q-sort rankings
Factor
Group 1 (N = 5)
Group 2 (N = 6)
Self-understanding Guidance Universality Existential factors Altruism Instillation of hope Catharsis Interpersonal learning Group cohesiveness
1 2 4 5 3 8 617 9 617
3 1 5 718 4 2 718 9 6
Group 3 (N = 5)
ble score for the 29 patients completing the Q-Sort is 580 and the lowest score is 116. The cardiac patients rated self-understanding and guidance highest. Universality, existential factors, altruism, and instillation of hope were ranked in a middle position; catharsis, interpersonal learning, and group co-
Group 4 (N = 5)
hesiveness
Group 5 (N = 5)
Group 6 (N = 4)
Cumulative score (N = 29)
Rank
l/2 l/2 6 314 5 314 7 8 9
1 2 3 4 617 5 617 9 8
455 453 379 366 361 360 303 288 275
1 2 3 4 5 6 7 8 9
were
placed
in the
least
preferred
group. Table 5 lists the six Q-Sort items (out of a total of 27) ranked highest by the patients. These include three guidance items (1,5, and 6), two self-understanding items (2,3), and one existential factor item
Table 5. Yalom Q-sort item rankings Item Highest ranked 1. Learning about coronary disease and its management, including an understanding of risk factors, general social/psychological vocation problems, and medical regimen. 2. Learning how my life-style plays a part in the development and management of cardiac heart disease. 3. Learning why I think and feel the way I do, ie., understanding some of the emotional sources of my problems. 4. Facing the basic issues of my life and death and thus living my life more honestly and being less caught up in trivialities. 5. The doctor or nurse suggesting or advising something for me to do. 6. Someone in the group giving definite suggestions about a life problem, ie, at work, with family. . Lowest ranked 22. Feeling more trustful of groups and of other people. 23. Recognizing that ultimately there is no escape from some of life’s pain and from death. 24. Improving my skills in getting along with people. 25. Developing close contacts with other people. 26. Expressing negative and/or positive feelings toward another member. 27. Revealing embarrassing things about myself and still being accepted by the group.
Factor
Guidance
Self-understanding
Self-understanding
Existential
Guidance Guidance
Interpersonal learning Existential Interpersonal learning Group cohesiveness Catharsis Group cohesiveness
105
M. J. Stern
(4). The table also includes those six items ranked lowest by the patients: Two are included under group cohesiveness (25,27), one under catharsis (21), two under interpersonal learning (22,24), and one under existential (23).
Discussion Medically ill patients have been described as rigid, cognitive, symtom-oriented, and unable to experience and express negative feelings, particularly aggression (16). In therapy they have presented themselves as aloof, detached individuals who avoid significant painful events unless directly solicited and who have little ability or motivation for selfexamination (17). Post-myocardial infarction patients have, in addition, been described as strong conformists, particularly in matters dealing with living up to social expectations and, in therapy, as highly focused on problems of everyday life (4). Our clinical observations during the course of this study support the above characterization while suggesting that it can be modified by a therapist who understands the patient’s value system, and is willing to engage the patient within his/her own therapeutic framework and then utilize the resulting therapeutic alliance to promote greater affective exploration of individual or shared group experiences. Study data indicate that cardiac patients in shortterm groups most value a therapeutic orientation in which they receive advice and guidance, learn positive qualities, and gain cognitive insight by learning how their lifestyle plays a role in the development and management of their coronary condition. On a process level, they engage in a dependency-oriented relationship with the therapist and secondarily become involved in a reciprocal relationship with other group members in which they are either of help (altruism) or are inspired in turn by the other patients’ success (instillation of hope). They avoid being confronted and challenged, experiencing negative feelings, and/or becoming anxious and depressed in the process of working through issues such as early object loss and/or narcissistic entitlement. From a clinical standpoint, the first and most unstructured group confirmed the difficulties previously reported in motivating medically ill patients to engage in self-exploration. The patients consistently attempted to focus the session on a discussion of their physical symptoms, medication, and prognosis. If a particular emotional issue not directly related to heart disease was raised, the mem106
bers tended to be supportive but quickly reverted back to their original cognitive, symptom-oriented approach. As already noted, we decided to alter the process format beginning with the second group in an attempt to enhance the effectiveness of the therapy. In keeping with the patients’ expressed interest in a positively focused and therapist-guided approach that stressed learning about coronary disease and its management, we spent two full sessions, using charts and slides when necessary, to answer any questions about pathophysiology, medications, procedures such as catheterization, and risk factors. In the next two sessions we stressed the role that lifestyle, particularly type A pattern behavior, plays in the development of heart disease, emphasizing during the discussion the patients’ capacity to make life adjustments by pacing themselves and tolerating delay as well as by reducing interpersonal hostility. We also taught and asked the patients to practice the Jacobsen Deep Muscle Relaxation Exercises as one behavioral means to reinforce the concept of relaxation. At this point in the therapy, one-half to twothirds of the original six patients in each of the groups appeared to have a strong therapeutic alliance with the therapists. They felt that their major questions about their myocardial infarction were answered and were stimulated by the concept of lifestyle change to share troubling problems in dealing with such issues as work, family, and sexual relations. They also explored, frequently for the first time, the possibility of altering life goals, discussing in the process the existential issue of life and death, and at least giving thought to being less caught up in trivialities. Throughout this portion of the sessions, members encouraged one another, although in keeping with their value system they avoided critique of those members who sat back and did not seem to be making changes. These latter one or two patients in each group frequently had to be encouraged and challenged by the group leaders. With rare exceptions, however, these patients remained committed to a cognitive medical approach and either left after several sessions or quietly sat through the process sessions, seemingly unaffected by what was going on around them. Comparison
with Other Groups
Previous research on therapeutic factors in group therapy points out the vast difference between cardiac patients and most other client groups in ranking the therapeutic factors. Whereas clinic patients
Postmyocardial Infarction Patients
expect getting insight from understanding the past, seeing undesirable things about self, and experiencing negative feelings on Lieberman’s questionnaire (14) and value interpersonal learning, catharsis, cohesiveness, and self-understanding as important in their therapeutic success on Yalom’s Q-Sort (15), the cardiac patients rank these factors with the exception of self understanding (or insight) at the bottom of their therapeutic value system. While this difference noted on the Q-sort could be questioned on the basis of the modifications we made, ie, shortening the original 60 items to 27 and modifying the language to be suitable for cardiac patients, the fact that the Lieberman questionnaire, where no changes were made, similarly differentiates between the clinic and cardiac patients tends to support the applicability of the Qsort results as well. Other group participants, i.e. NTL and Growth Center clients, differ markedly in their group process expectations from both the cardiac and clinic patients. Lieberman (14) has reported that for these subjects, experiencing excitement and joy and being confronted and challenged ranked highest while getting insight, revealing secrets, and receiving advice ranked lowest. Similarly, utilizing Yalom’s questionnaire, Maxmen (18) has shown that hospitalized patients differ from clinic patients in that they rank instillation of hope, cohesiveness, altruism, and universality of greatest use to them following short-term therapy. Narcotic addicts participating in a variety of group modalities over a lto 2-year rehabilitation period have still another Qsort rank ordering (19). For them, insight, existential factors (particularly taking ultimate responsibility for the way they live their lives), and catharsis are most crucial. Perhaps the one group whose expectations are somewhat similar to those of the cardiac patients are members of women’s consciousness-raising (C-R) groups (14). Both highly rate learning positive qualities and getting understanding from the past while downgrading becoming anxious and depressed, experiencing negative feelings, and seeing undesirable things about oneself. One possible reason for this similarity is that members in both groups report feeling different and alone and experience a sense of restless constraint (20). These issues are dealt with as members in both groups gain insight by comparing personal experiences and set up new goals where positive qualities are highlighted. The C-R women differ from the cardiac
patients in that many of their groups are based on the assumption that the environment rather than
intrapsychic dynamics plays a major role in their difficulties (21). In assuming an adversarial role, they rate highly factors such as gaining group support in asserting themselves, experiencing excitement and joy (in learning new behaviors or just being together), and revealing secrets. The cardiac patients, while viewing their physical condition as their major problem, do not disown the problem. Rather, they look to caregivers for advice and guidance on how to cope with their physical and psychological reactions. The sum total of this overview of differential valuing of therapeutic factors by different patient groups appears to be that it is most important to assess what each patient (or client) group is looking for and adjust therapeutic interventions to be as consonant as possible with these expectations. This will help ensure that a positive, effective alliance between patient and therapist develops. Insofar as the treatment of cardiac and possibly other somatically ill patients is concerned, interventions encouraging catharsis and interpersonal confrontation would appear to be counterproductive while education, promotion of self-understanding, and encouraging the learning of new positively-oriented behaviors would appear to be therapeutically beneficial.
References 1. Pratt JH: Treatment of tuberculosis by class method. JAMA 49:755-759, 1907 2. Pratt JH: The principles of class treatment and their application to various chronic diseases. Hosp Social Serv J. 6:401-408, 1922 3. Titchener JS, Sheldon MB, Ross WD: Changes in blood pressure of hypertensive patients with and without group therapy. J Psychosom Res 4:10-13, 1959 4. Ibrahim MS, Feldman JG, Sultz HA, et al: Management after myocardial infarction: A controlled trial of the effect of group psychotherapy. Int J Psychiatry Med 5:253-268, 1974 5. Rahe RH, O’Neil T, Hagen A, et al: Brief group therapy following myocardial infarction: Eighteen-month follow-up of a controlled trial. Int J Psychiatry Med 6349-358, 1975 6. Chafetz ME, Bernstein N, Sharpe W, et al: Short term group therapy of patients with Parkinson’s disease. N Engl J Med 253:961-964, 1955 Hartings MF, Pavlov M, Davis F: Group counseling of MS patients in a program of comprehensive care. J Chron Dis 2965-73, 1976 Groen JJ, Pelser HE: Experiences with and results of group psychotherapy in patients with bronchial asthma. J Psychosom Res 4:191-205, 1960 Pattison EM, Rhodes RJ, Dudley DL: Response to group treatment in patients with severe chronic lung disease. Int J Group Psychother 21:214-225, 1971 107
M. J. Stem
10. Spiegel D, Bloom J, Yalom I: Group support for pa-
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
tients with metastatic cancer. Arch Gen Psychiatry 38:527-533, 1981 Buchanan DC: Group therapy for kidney transplant patients. Int J Psychiatry Med 6:523-530, 1975 Lennenberg E: QT in Boston-iIeostomy group. N Engl J Med 251:1008-1010, 1954 Yalom ID, Greaves C: Group therapy with the terminally ill. Am J Psychiatry 134:396-400, 1977 Lieberman MA: Problems in integrating traditional group therapies with new group forms. Int J Group Psychother 27:19-22, 1977 Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic, 1975, pp 74-83 Reckless J, Fauntleroy A: Groups, spouses and hospitalization as a trial of treatment in psychosomatic illness. Psychosomatics 13:353-357, 1972 Karasu TB: Psychotherapy of the medically ill. Am J Psychiatry 136:1-11, 1979 Maxmen JS: Group therapy as viewed by hospitalized patients. Arch Gen Psychiatry 28:404-408, 1973 Steinfeld G, MabIi J: Perceived curative factors in group therapy by residents of a therapeutic community. Crimin Justice Behav 1:278-288, 1974 Bird C: Born Female: The High Cost of Keeping Women Down. New York, McKay, 1968 Brodsky AM: The consciousness-raising group as a model for therapy with women. Psychother Theory Res Pratt 10:24-29, 1973
Appendix
4.
Guidance 4-l The doctor or nurse suggesting or advising something for me to do 42 Someone in the group giving definite suggestions about a life problem, ie, at work, with family 43 Learning about coronary disease and its management, including an understanding of risk factors, general social/psychological/ vocation problems and medical regimen
5.
Catharsis 5-l Being able to talk about my fears 5-2 Being able to reveal my feelings instead of holding them in 5-3 Expressing negative and/or positive feelings toward another member
6.
Self-understanding 6-l Becoming aware of my true feelings about my condition 6-2 Learning how my life-style plays a part in the development and management of cardiac heart disease 6-3 Learning why I think and feel the way I do, ie, understanding some of the emotional sources of my problems
7.
Instillation of hope 7-l Seeing that others were adapting well to their heart conditions inspired me 7-2 Seeing that others had solved problems similar to mine 7-3 Seeing that other group members improved encouraged me
8.
Existential factors Recognizing that ultimately there is no escape from some of life’s pain and from death 8-2 Learning that I must take ultimate responsibility for the way I live my life 8-3 Facing the basic issues of my life and death and thus living my life more honestly and being less caught up in trivialities
Modified Version of Yalom’s Curative Factors Q-Sort 1.
Altruism l-l
Being able to help other group members by
1-2
Being able to forget my problems and think
l-3
of helping others Being able to give part of myself to others
giving them encouragement and advice
2.
Group Cohesiveness 2-1 Being understood and accepted by other group members 2-2 Developing close contacts with other people 2-3 Revealing embarrassing things about myself and still being accepted by the group
3.
Universality 3-l Learning that I was no different from other cardiac patients 3-2 Learning that other members had some of the same thoughts and feelings that I did 3-3 Learning that other group members were facing the same kinds of problems that I did
108
8-1
9.
Interpersonal learning 9-l Group members honestly telling me what they think of me and the way I do things 9-2 Improving my skills in getting along with people 9-3 Feeling more trustful of groups and of other people
of Psychiatry
Elizabeth Plionis, DSW Research Associate
Leanne Kaslow, MSW Research Associate,
George Washington
University,
Abstract: Post-myocardial infarction patients participating
Washington,
in
a 12-session group therapy program completed self-rating measures ranking group process variables before and after therapy. Learning positive qualities, experimenting with new behavior, receiving advice and guidance,and gaining cognitive insight by learning how their lifestyle plays a role in the development and management of their coronary condition were most valued. Interpersonal learning, catharsis, and testing group acceptance by revealing embarrassing things about oneself were ranked lowest. These results are examined in the context of previous descriptions of coronary patients’ behavior in therapy.
Group therapy with medically ill patients has a long history in modern psychiatry. The pioneer work was done by Pratt (1) who, in 1907, described what he referred to as the class method for treating tuberculous patients. His technique was to tell patients about their disease, encourage them to suppress worrisome thoughts and wishes, and inspire them to find an interest in life. Pratt subsequently applied his method to treating diabetic and cardiac patients (2). Others have since used group methods in treating patients with a variety of medical syndromes, including hypertension (3), myocardial infarction (4,5), Parkinsonism (6), multiple sclerosis (7), asthma (8), chronic lung disease (9), and metastatic cancer (10). Post-transplant (ll), ileostomy (12),
Supported in part by grant no. G008003044 from the National Institute of Handicapped Research, Department of Education, Washington, D.C.
General Hospital Psychiatry 6, 101-108, 1984 0 Elsevie Science Publishing Co., Inc. i984 52 Vanderbilt Avenue, New York, NY 10017
D.C.
and terminally ill (13) patients have also participated in group therapy. All of the medical groups have shared certain characteristics. They have tended to be homogeneous in composition (based on commonality of illness or symptomatology) and short term (20 sessions or fewer). They have stressed education about the illness in question and support for group members in coping with the effects of their illness, both on an individual basis and in relation to family members, peers, and work colleagues. Group sessions have been described as being suffused with a clublike atmosphere, with members working to help one another solve problems of daily life, particularly in relation to the illness that brought them to the group. At times, however, the group gestalt has been reported to shift to that of a classroom, where education on the disease process and compliance with the medical regimen have been the major goals. More rarely, the medical group has functioned similarly to a psychodynamic group in working to resolve intrapsychic and interpersonal conflicts. The purpose of this study was to begin to define in a more rigorous way those group process variables that medical patients consider important in making use of group therapy. Such information could facilitate the development of a schematic model of group therapy that might address the needs of medically ill patients in a more effective manner. 101 ISSN 0163-8343B4Kl.00
M. J. Stern
Method Thirty-five post-myocardial infarction patients were randomly assigned to a 12-session group counseling program as part of a larger controlled study comparing the relative rehabilitation efforts of group counseling with a graduated exercise training program. The subjects were men and women between 30 and 69 years of age who had a documented myocardial infarction not less than six weeks or more than one year prior to admission to the study. They had either impaired exercise tolerance (seven METS or less for men and six METS or less for women) or anxiety/depression (a raw score of at least 19 on the Taylor Manifest Anxiety Scale and at least 40 on the Zung Self-Rating Depression Scale) at the time of the screening; were willing to be randomized and were able to participate fully in all evaluations and treatment sessions for the length of the study; had no medical or emotional conditions (specified) that would preclude participation in any part of the study; and were not participating in another counseling or graduated exercise training program. After being admitted to the study, patients were randomized in blocks of six to either a group counseling, exercise, or control group. Assignment to group counseling entailed participation in a series of 12 weekly 60-minute sessions led by an experienced group therapist (M.S.), a social worker, and at times a nurse clinician. The goals of the group were to 1) improve the patient’s understanding of his/her illness as well as offer help with specific problems that might arise eg, work, family, diet; 2) provide a forum for ventilation and expression of feelings, improve interpersonal communication and reduce the sense of isolation each member might feel without group support; 3) develop an awareness of pre-illness behavior patterns that may have contributed to the illness, eg, type A behavior; 4) enhance ego strengths and reduce reliance on unhealthy defense mechanisms such as hypochondriasis and depression; and 5) provide positive techniques to help patients with chronic free-floating anxiety through deep muscle relaxation exercises. The first therapy group was conducted in an open-ended manner. In the opening session members introduced themselves to one another by providing accounts of their heart attack and subsequent convalescence. The group leader provided an overall perspective on problems encountered in the post-myocardial infarction period, acquainted the 102
members with the basic principles of group participation, and encouraged them to talk freely about any topic they wished. In subsequent sessions the members discussed many areas of stress in their lives. However, the sessions bore little relationship to one another, had no sense of continuity, and were frequently interrupted by questions indicating the group members’ lack of understanding of the pathophysiology of heart attacks and indications for medication and/or certain procedures such as catheterization. These questions would frequently disrupt the group process as members switched from members of a work-oriented group to being dependent on the leaders for information. To remedy this situation, beginning with the second 12-session group, we altered the group format so that the more structured education and behavioral methodology, supplemented by reading material and relaxation exercises, was provided in the initial five sessions. The remaining sessions were set aside for more process-oriented work. This change produced the desired effect. Members were less distracted by lack of knowledge of their coronary condition and devoted most of their time and effort in group to tackling troublesome life problems. Discussion focused upon issues such as stress at work (coping with feelings of insecurity over holding onto one’s job, obtaining promotions and/or not being treated by others as being over the hill versus concerns about not getting too worked up at conferences, or fears about working overly long hours), at home (particularly applicable to women who tended to feel overprotected, frequently against their better judgment), socially (countering a tendency towards withdrawal and isolation), sexually (worrying whether resumption of sex would lead to a recurrent infarction), physically (worries over another infarction, invalidism and/or death, particularly when experiencing complications such as angina, arrhythmias, and shortness of breath), and/or in relation to the need to diet, discontinue smoking, or increase physical activity levels. In the final session members participated in a summary discussion and general critique of work done in the group and completed questionnaires designed to assess their impressions of the group process.
Evaluation Instruments Two methods of evaluating the saliency of the group process were used. The first, a rank order questionnaire developed by Lieberman (14) to as-
PostmyocardialInfarction Patients
sess the relative importance of 11 group process items, was administered before the start of counseling and at the beginning of the last counseling session. This instrument assessed change (if any) in patient perception of the relative importance of the group process items over the 12-week period of counseling. A second evaluation measure, a modified version of Yalom’s Curative Factors in Group Therapy Q-Sort (15), was administered only at the beginning of the last group counseling session. The Q-Sort adds to the information obtained from the Lieberman questionnaire in that it is more comprehensive and provides an in-depth view of the patient’s assessments of those items which were of benefit during the group therapy sessions. Yalom’s Q-Sort consists of 11 curative factors: altruism, group cohesiveness, universality, guidance, catharsis, selfunderstanding, instillation of hope, existential factors, interpersonal learning, identification, and family re-enactment. We modified the Q-Sort by eliminating the identification and family re-enactment factors (because these factors were judged to be more suitable for a younger population); by reducing the descriptive items subsumed under each factor from five to three, thereby making the instrument more concise and able to be completed in a shorter period of time (approximately 20 minutes); and, wherever necessary, by changing the item
Table 1. Sociodemographic characteristics No.
Characteristic Sex
31 4
Male Female Race White Black Age 48 49-58 259 Social classa 1 2-3 4-5 Marital status Married Other ‘Hollingshead
Two-Factor
28 7 9 12 14 8 19 8 30 5 Index.
wording so that each item had relevance for a coronary patient population, ie, under “guidance” we inserted the descriptive item “learning about coronary disease and its management” (see appendix).
Results Table 1 provides a sociodemographic profile of the 35 patients randomized into group counseling. They are predominantly white, married, middle to upper middle class males with a mean age of 54.7 years. Twenty-two patients (63%) began participating in the study within six months of their heart attack. Fourteen patients (40%) reported having at least one counseling session with an outside mental health professional prior to entering the study. Of these, three patients had had between two and five counseling sessions and five patients had had six sessions to over a year’s therapy.
Attendance Twenty-six patients (74%) attended more than three-quarters of the sessions. Five patients (15%) attended between half and three-quarters of the sessions and four (11%) dropped out within the first three sessions. The only sociodemographic differences between the four dropouts and the remainder of the patients was that all were male and two were black. No differences were noted between the five patients attending one-half to threequarters of the sessions and the remainder of the patients.
Lieberman Group Process Expectations Questionnaire Table 2 lists group members’ ranking of Lieberman Questionnaire items before beginning therapy. On this questionnaire, the numerical score is inversely related to rank; the higher the score, the lower the ranking. The lowest cumulative score possible, if all subjects completing the questionnaire were to rank an item as number one, is 29, and the highest possible score is 319. The cardiac patients ranked learning positive qualities highest. Getting insight from the past, experimenting with new behavior, and receiving advice followed next. These four items rounded out the most important expectations. Being confronted and challenged, being supported and valued, seeing undesirable things about oneself, and experiencing excitement and joy occupied a middle position. Revealing secrets, experi103
M. J. Stern
Table 2. Group process expectation
Item Learn positive qualities Get insight from past Experiment with new behavior Receive advice Be confronted and challenged Be supported and valued See undesirable things Experience job and excitement Reveal secrets Experience negative feelings
Become anxious and depressed
rankings before group counseling
Group 1 (N = 5) 1
314 314 5 6 2 718 718 9 10 11
Group 2 (N = 6)
Group 3 (N = 5)
1
1
2 3 4 6 5 8 7 9 10 11
2 5 3 4 6 7 8 9 10 11
encing negative feelings, and becoming anxious and depressed occupied the least desirable level. The last item, becoming anxious and depressed, came close to achieving a perfect negative score. As Table 2 shows, there is some intergroup variation in ranking. In general, the four highest items remain most desirable for at least two-thirds of the groups, and the three least desirable items remain so for almost all groups. Following completion of group counseling, the same 29 members rated the group experience (Table 3). Ranking remained essentially unchanged. One exception was that receiving advice moved to third position and experimenting with new behavior moved to fourth. There also appeared to be a stronger clustering of the first three items, learning positive qualities, getting insight from the past, and receiving advice; experimenting
Group 4 (N = 4)
Group 5 (N = 5)
3 4 7 2 6 1 5 8 11 9 10
4 6 1 5 3 9 7 2 10 8 11
Group 6 (N = 4)
5 l/2 l/2 4 6 7 3 10 9 8 11
Cumulative score (N = 29)
Rank
86 111 119 123 151 167 173 180 256 256 294
1 2 3 4 5 6 7 8 9110 9110 11
with new behavior (previously in the first category) moved closer to the secondary values of being confronted and challenged and being supported and valued. These are clearly very minor alterations considering the multiple possible combinationsand permutations. As with the pregroup ranking, there is some intergroup variation in the postgroup assessment. However, the difference in ranking is even less for the postgroup assessment. Five-sixths of the groups rated the first three items highest and, with one exception, all rated the last three items lowest.
Yalom Q-Sort Table 4 presents a rank ordering of the nine selected Yalom Q-Sort factors. The highest score is correlated with the most valued rank. The highest possi-
Table 3. Group process expectation rankings after group counseling
Item Learn positive qualities Get insight from the past Receive advice Experiment with new behavior Be confronted and challenged Be supported and valued See undesirable things Experience joy and excitement Reveal secrets Experience negative feelings Become anxious and depressed
104
Group 1 (N = 5)
Group 2 (N = 6)
Group 3 (N = 5)
3 2 1 5 7 4 8 6 9 10
2 1 4 3 6 5 8 7 9 10 11
2 3 7 5 6 4 8 9 10 11
11
1
Group 4 (N = 5) 1
2 3 4 5 7 6 9 11 10 8
Group 5 (N = 5)
Group 6 (N = 4)
Cumulative score (N = 29)
Rank
6 415 1 2 415 8 3 7 9 11 10
1 2 3 5 8 4 7 6 9 10 11
90 91 102 137 160 165 181 200 271 280 296
1 2 3 4 5 6 7 8 9 10 11
Postmyocardial Infarction Patients
Table 4. Yalom Q-sort rankings
Factor
Group 1 (N = 5)
Group 2 (N = 6)
Self-understanding Guidance Universality Existential factors Altruism Instillation of hope Catharsis Interpersonal learning Group cohesiveness
1 2 4 5 3 8 617 9 617
3 1 5 718 4 2 718 9 6
Group 3 (N = 5)
ble score for the 29 patients completing the Q-Sort is 580 and the lowest score is 116. The cardiac patients rated self-understanding and guidance highest. Universality, existential factors, altruism, and instillation of hope were ranked in a middle position; catharsis, interpersonal learning, and group co-
Group 4 (N = 5)
hesiveness
Group 5 (N = 5)
Group 6 (N = 4)
Cumulative score (N = 29)
Rank
l/2 l/2 6 314 5 314 7 8 9
1 2 3 4 617 5 617 9 8
455 453 379 366 361 360 303 288 275
1 2 3 4 5 6 7 8 9
were
placed
in the
least
preferred
group. Table 5 lists the six Q-Sort items (out of a total of 27) ranked highest by the patients. These include three guidance items (1,5, and 6), two self-understanding items (2,3), and one existential factor item
Table 5. Yalom Q-sort item rankings Item Highest ranked 1. Learning about coronary disease and its management, including an understanding of risk factors, general social/psychological vocation problems, and medical regimen. 2. Learning how my life-style plays a part in the development and management of cardiac heart disease. 3. Learning why I think and feel the way I do, ie., understanding some of the emotional sources of my problems. 4. Facing the basic issues of my life and death and thus living my life more honestly and being less caught up in trivialities. 5. The doctor or nurse suggesting or advising something for me to do. 6. Someone in the group giving definite suggestions about a life problem, ie, at work, with family. . Lowest ranked 22. Feeling more trustful of groups and of other people. 23. Recognizing that ultimately there is no escape from some of life’s pain and from death. 24. Improving my skills in getting along with people. 25. Developing close contacts with other people. 26. Expressing negative and/or positive feelings toward another member. 27. Revealing embarrassing things about myself and still being accepted by the group.
Factor
Guidance
Self-understanding
Self-understanding
Existential
Guidance Guidance
Interpersonal learning Existential Interpersonal learning Group cohesiveness Catharsis Group cohesiveness
105
M. J. Stern
(4). The table also includes those six items ranked lowest by the patients: Two are included under group cohesiveness (25,27), one under catharsis (21), two under interpersonal learning (22,24), and one under existential (23).
Discussion Medically ill patients have been described as rigid, cognitive, symtom-oriented, and unable to experience and express negative feelings, particularly aggression (16). In therapy they have presented themselves as aloof, detached individuals who avoid significant painful events unless directly solicited and who have little ability or motivation for selfexamination (17). Post-myocardial infarction patients have, in addition, been described as strong conformists, particularly in matters dealing with living up to social expectations and, in therapy, as highly focused on problems of everyday life (4). Our clinical observations during the course of this study support the above characterization while suggesting that it can be modified by a therapist who understands the patient’s value system, and is willing to engage the patient within his/her own therapeutic framework and then utilize the resulting therapeutic alliance to promote greater affective exploration of individual or shared group experiences. Study data indicate that cardiac patients in shortterm groups most value a therapeutic orientation in which they receive advice and guidance, learn positive qualities, and gain cognitive insight by learning how their lifestyle plays a role in the development and management of their coronary condition. On a process level, they engage in a dependency-oriented relationship with the therapist and secondarily become involved in a reciprocal relationship with other group members in which they are either of help (altruism) or are inspired in turn by the other patients’ success (instillation of hope). They avoid being confronted and challenged, experiencing negative feelings, and/or becoming anxious and depressed in the process of working through issues such as early object loss and/or narcissistic entitlement. From a clinical standpoint, the first and most unstructured group confirmed the difficulties previously reported in motivating medically ill patients to engage in self-exploration. The patients consistently attempted to focus the session on a discussion of their physical symptoms, medication, and prognosis. If a particular emotional issue not directly related to heart disease was raised, the mem106
bers tended to be supportive but quickly reverted back to their original cognitive, symptom-oriented approach. As already noted, we decided to alter the process format beginning with the second group in an attempt to enhance the effectiveness of the therapy. In keeping with the patients’ expressed interest in a positively focused and therapist-guided approach that stressed learning about coronary disease and its management, we spent two full sessions, using charts and slides when necessary, to answer any questions about pathophysiology, medications, procedures such as catheterization, and risk factors. In the next two sessions we stressed the role that lifestyle, particularly type A pattern behavior, plays in the development of heart disease, emphasizing during the discussion the patients’ capacity to make life adjustments by pacing themselves and tolerating delay as well as by reducing interpersonal hostility. We also taught and asked the patients to practice the Jacobsen Deep Muscle Relaxation Exercises as one behavioral means to reinforce the concept of relaxation. At this point in the therapy, one-half to twothirds of the original six patients in each of the groups appeared to have a strong therapeutic alliance with the therapists. They felt that their major questions about their myocardial infarction were answered and were stimulated by the concept of lifestyle change to share troubling problems in dealing with such issues as work, family, and sexual relations. They also explored, frequently for the first time, the possibility of altering life goals, discussing in the process the existential issue of life and death, and at least giving thought to being less caught up in trivialities. Throughout this portion of the sessions, members encouraged one another, although in keeping with their value system they avoided critique of those members who sat back and did not seem to be making changes. These latter one or two patients in each group frequently had to be encouraged and challenged by the group leaders. With rare exceptions, however, these patients remained committed to a cognitive medical approach and either left after several sessions or quietly sat through the process sessions, seemingly unaffected by what was going on around them. Comparison
with Other Groups
Previous research on therapeutic factors in group therapy points out the vast difference between cardiac patients and most other client groups in ranking the therapeutic factors. Whereas clinic patients
Postmyocardial Infarction Patients
expect getting insight from understanding the past, seeing undesirable things about self, and experiencing negative feelings on Lieberman’s questionnaire (14) and value interpersonal learning, catharsis, cohesiveness, and self-understanding as important in their therapeutic success on Yalom’s Q-Sort (15), the cardiac patients rank these factors with the exception of self understanding (or insight) at the bottom of their therapeutic value system. While this difference noted on the Q-sort could be questioned on the basis of the modifications we made, ie, shortening the original 60 items to 27 and modifying the language to be suitable for cardiac patients, the fact that the Lieberman questionnaire, where no changes were made, similarly differentiates between the clinic and cardiac patients tends to support the applicability of the Qsort results as well. Other group participants, i.e. NTL and Growth Center clients, differ markedly in their group process expectations from both the cardiac and clinic patients. Lieberman (14) has reported that for these subjects, experiencing excitement and joy and being confronted and challenged ranked highest while getting insight, revealing secrets, and receiving advice ranked lowest. Similarly, utilizing Yalom’s questionnaire, Maxmen (18) has shown that hospitalized patients differ from clinic patients in that they rank instillation of hope, cohesiveness, altruism, and universality of greatest use to them following short-term therapy. Narcotic addicts participating in a variety of group modalities over a lto 2-year rehabilitation period have still another Qsort rank ordering (19). For them, insight, existential factors (particularly taking ultimate responsibility for the way they live their lives), and catharsis are most crucial. Perhaps the one group whose expectations are somewhat similar to those of the cardiac patients are members of women’s consciousness-raising (C-R) groups (14). Both highly rate learning positive qualities and getting understanding from the past while downgrading becoming anxious and depressed, experiencing negative feelings, and seeing undesirable things about oneself. One possible reason for this similarity is that members in both groups report feeling different and alone and experience a sense of restless constraint (20). These issues are dealt with as members in both groups gain insight by comparing personal experiences and set up new goals where positive qualities are highlighted. The C-R women differ from the cardiac
patients in that many of their groups are based on the assumption that the environment rather than
intrapsychic dynamics plays a major role in their difficulties (21). In assuming an adversarial role, they rate highly factors such as gaining group support in asserting themselves, experiencing excitement and joy (in learning new behaviors or just being together), and revealing secrets. The cardiac patients, while viewing their physical condition as their major problem, do not disown the problem. Rather, they look to caregivers for advice and guidance on how to cope with their physical and psychological reactions. The sum total of this overview of differential valuing of therapeutic factors by different patient groups appears to be that it is most important to assess what each patient (or client) group is looking for and adjust therapeutic interventions to be as consonant as possible with these expectations. This will help ensure that a positive, effective alliance between patient and therapist develops. Insofar as the treatment of cardiac and possibly other somatically ill patients is concerned, interventions encouraging catharsis and interpersonal confrontation would appear to be counterproductive while education, promotion of self-understanding, and encouraging the learning of new positively-oriented behaviors would appear to be therapeutically beneficial.
References 1. Pratt JH: Treatment of tuberculosis by class method. JAMA 49:755-759, 1907 2. Pratt JH: The principles of class treatment and their application to various chronic diseases. Hosp Social Serv J. 6:401-408, 1922 3. Titchener JS, Sheldon MB, Ross WD: Changes in blood pressure of hypertensive patients with and without group therapy. J Psychosom Res 4:10-13, 1959 4. Ibrahim MS, Feldman JG, Sultz HA, et al: Management after myocardial infarction: A controlled trial of the effect of group psychotherapy. Int J Psychiatry Med 5:253-268, 1974 5. Rahe RH, O’Neil T, Hagen A, et al: Brief group therapy following myocardial infarction: Eighteen-month follow-up of a controlled trial. Int J Psychiatry Med 6349-358, 1975 6. Chafetz ME, Bernstein N, Sharpe W, et al: Short term group therapy of patients with Parkinson’s disease. N Engl J Med 253:961-964, 1955 Hartings MF, Pavlov M, Davis F: Group counseling of MS patients in a program of comprehensive care. J Chron Dis 2965-73, 1976 Groen JJ, Pelser HE: Experiences with and results of group psychotherapy in patients with bronchial asthma. J Psychosom Res 4:191-205, 1960 Pattison EM, Rhodes RJ, Dudley DL: Response to group treatment in patients with severe chronic lung disease. Int J Group Psychother 21:214-225, 1971 107
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10. Spiegel D, Bloom J, Yalom I: Group support for pa-
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tients with metastatic cancer. Arch Gen Psychiatry 38:527-533, 1981 Buchanan DC: Group therapy for kidney transplant patients. Int J Psychiatry Med 6:523-530, 1975 Lennenberg E: QT in Boston-iIeostomy group. N Engl J Med 251:1008-1010, 1954 Yalom ID, Greaves C: Group therapy with the terminally ill. Am J Psychiatry 134:396-400, 1977 Lieberman MA: Problems in integrating traditional group therapies with new group forms. Int J Group Psychother 27:19-22, 1977 Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic, 1975, pp 74-83 Reckless J, Fauntleroy A: Groups, spouses and hospitalization as a trial of treatment in psychosomatic illness. Psychosomatics 13:353-357, 1972 Karasu TB: Psychotherapy of the medically ill. Am J Psychiatry 136:1-11, 1979 Maxmen JS: Group therapy as viewed by hospitalized patients. Arch Gen Psychiatry 28:404-408, 1973 Steinfeld G, MabIi J: Perceived curative factors in group therapy by residents of a therapeutic community. Crimin Justice Behav 1:278-288, 1974 Bird C: Born Female: The High Cost of Keeping Women Down. New York, McKay, 1968 Brodsky AM: The consciousness-raising group as a model for therapy with women. Psychother Theory Res Pratt 10:24-29, 1973
Appendix
4.
Guidance 4-l The doctor or nurse suggesting or advising something for me to do 42 Someone in the group giving definite suggestions about a life problem, ie, at work, with family 43 Learning about coronary disease and its management, including an understanding of risk factors, general social/psychological/ vocation problems and medical regimen
5.
Catharsis 5-l Being able to talk about my fears 5-2 Being able to reveal my feelings instead of holding them in 5-3 Expressing negative and/or positive feelings toward another member
6.
Self-understanding 6-l Becoming aware of my true feelings about my condition 6-2 Learning how my life-style plays a part in the development and management of cardiac heart disease 6-3 Learning why I think and feel the way I do, ie, understanding some of the emotional sources of my problems
7.
Instillation of hope 7-l Seeing that others were adapting well to their heart conditions inspired me 7-2 Seeing that others had solved problems similar to mine 7-3 Seeing that other group members improved encouraged me
8.
Existential factors Recognizing that ultimately there is no escape from some of life’s pain and from death 8-2 Learning that I must take ultimate responsibility for the way I live my life 8-3 Facing the basic issues of my life and death and thus living my life more honestly and being less caught up in trivialities
Modified Version of Yalom’s Curative Factors Q-Sort 1.
Altruism l-l
Being able to help other group members by
1-2
Being able to forget my problems and think
l-3
of helping others Being able to give part of myself to others
giving them encouragement and advice
2.
Group Cohesiveness 2-1 Being understood and accepted by other group members 2-2 Developing close contacts with other people 2-3 Revealing embarrassing things about myself and still being accepted by the group
3.
Universality 3-l Learning that I was no different from other cardiac patients 3-2 Learning that other members had some of the same thoughts and feelings that I did 3-3 Learning that other group members were facing the same kinds of problems that I did
108
8-1
9.
Interpersonal learning 9-l Group members honestly telling me what they think of me and the way I do things 9-2 Improving my skills in getting along with people 9-3 Feeling more trustful of groups and of other people