Group-Based Cognitive and Psychosocial Interventions

1. Group-Based Cognitive and Psychosocial Interventions Rhonda M. Williams, PhD. MS Center of Excellence West VA Puget Sound University of Washington

2. 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

3. Individual Psychotherapy Medical Treatment & Education, Skills Training Peer Support Psychological Needs of Person with MS

4. Individual Psychotherapy Group Psychotherapy Medical Treatment & Education, Skills Training Peer Support

5. 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

6. 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)

7. 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

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

9. 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

10. Cognitive Behavioral Therapy Mutual Support Group Professional Leader Paraprofessional Leader 21% Depression alleviated (N=19) 46% Depression alleviated (N=22) 58% Depression Alleviated (N=22) 29% Depression alleviated (N=29) 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)

11. 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).

12. 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)

13. Groups Scientifically validated, predetermined Enhancing social support Active coping Emotional Expression Reprioritizing Individual Patient’s personal concerns Personal relationship problems Functional changes, losses Group vs. Individual Therapy Topics

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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?

20. 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

21. 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)

22. 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).

23. 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

24. 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)

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

26. 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