A preliminary report on innovative group therapy in an oncology in‐patient department: a patient–family–staff community meeting

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  A preliminary report on innovative group therapy in an oncology in‐patient department: a patient–family–staff community meeting
  Psycho-Oncology Psycho-Oncology   20 : 1126–1129 (2011)Published online 25 July 2010 in Wiley Online Library (wileyonlinelibrary.com).  DOI : 10.1002/pon.1813 Brief Report A preliminary report on innovative group therapy in anoncology in-patient department: a patient–family–staff community meeting Liron Eliasov  , Daniela Zalman, Ezequiel Flechter, Marina Vorobeichik, Michal Halevi-Gurevich, Inbal Leviand Gil Bar-Sela Division of Oncology, Rambam-Health Care Campus, and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Abstract Objective : The Community Meeting (CM) is a unique form of group therapy applied fromPsychiatry to an Oncology in-patient department. It is designed to answer the needs of in-patientsand family members for open communication and empathic interaction and to serve as a modelfor effective coping. Methods : A weekly staff–patient–family open group was held, with facilitation based on anintegrative crisis intervention model. After each CM, the staff meets to discuss implications. Results : Frequent themes include patient and caregiver concerns about cancer, treatments,communication and coping difficulties. Subjective impressions of participants indicate positiveoutcomes. The CM seems to enhance positive interactions and perceived quality of care.It helps staff to identify distress, serves as a managerial tool and promotes collaboration amongstaff. Conclusions : The CM is a unique method for addressing the burdens of in-patient oncologymembers. A structured study is needed to substantiate these descriptive outcomes.Copyright r 2010 John Wiley & Sons, Ltd. Keywords: cancer; oncology; Community Meeting; group therapy; communication Introduction More than half Radiotherapy Department in-patients were found to be vulnerable to mentaland behavioral disorders [1], which increase withdisease severity and longer hospital stay [2].Hospitalization increases loneliness, boredom andlack of control [3]. Family caregivers’ burden andsatisfaction of care during hospitalization areinfluenced by various staff behaviors such asopen communication, timely information, greateraccess to physician’s time and empathic interac-tions [4–6]. These findings raise the need forimproving the quality of interactions betweenstaff, patients and caregivers. We suggest thatthe method of a Community Meeting (CM) mayanswer this need.The CM is a common form of treatment inPsychiatric in-patient departments, where staff-patient meetings are held regularly. The meeting’saims include articulation of needs, management of department tasks, addressing interpersonal relation-ships [7] and confronting hidden aspects of partici-pants [8]. In a literature survey, we found no reportsof applying the CM to nonpsychiatric settings.emphasizing the uniqueness and innovation of applying the CM to a general hospital. Althoughgroup therapy is a common and effective interven-tion for cancer patients [9–12], we found no reportof an intervention similar to a CM.The rationale for conducting a CM in theRadiotherapy Department is based on the rela-tively long periods of admissions (average 5 weeks),along with a population of high status performancepatients who interact on various levels with otherpatients, staff and family members. These personsform a community which is not addressed expli-citly. By conducting the CM in this department, weprovide a concrete space for the community,promoting the concepts of a ‘Therapeutic Com-munity’ [13] and a ‘sense of a community’ [14].The Radiotherapy Department’s CM goals areto promote open communication and empathicinteraction between members and specifically withsenior staff; to provide a forum for sharingthoughts and feelings constructively; and to pro-vide professional information and departmentpolicies. We assume that these goals will contributeto better coping and improvement in perceivedquality of care. In addition, the CM should assistthe staff on a clinical and managerial level, andstrengthen staff collaboration. *Correspondence to: Divisionof Oncology, Rambam-Health Care Campus, POB9602, Haifa 31096, Israel.E-mail:lironeliasov@gmail.com Received: 10 November 2009Revised: 9 June 2010Accepted: 15 June 2010 Copyright r 2010 John Wiley & Sons, Ltd.  Method The CM in the Radiotherapy In-Patient Depart-ment takes place in the lounge once weekly for45min. Recruiting emphasizes that participation isoptional and that participants may enter or leavethe session according to their own needs. Partici-pants include patients, family caregivers and staff of various religious (Jewish, Moslem, Christian,Druze) and cultural backgrounds (Arab,Ethiopian, North African and Eastern/WesternEuropean). The number of participants rangesfrom 10 to 20 on average. Participating patients arehospitalized for various medical needs, rangingfrom active radiation therapy, oncological emer-gencies, treatment complications and symptombalancing to supportive and end-of-life treatments.Patients vary in cancer type, time from diagnosisand stage. Approximately 25% of the participatingpatients participate only once, while most partici-pate for the duration of their admission (these wetermed ‘veterans’). About 30% of patients areaccompanied by family members. Relatives areusually of first-degree, above 18 years of age, andcan attend without the patient.The meeting is conducted in Hebrew with breaksfor translation to Russian or Arabic (the other mostcommon languages in Israel) when needed. Theparticipating staff includes the head physician, headnurse, department social worker and the psycholo-gist who facilitates the meeting. The meeting is semi-structured [15]. Structure is needed because of theheterogeneous population and frequent one-timeparticipation. Structure is achieved by a set openingand closing statement and directive facilitation. Theopening statement relates to the setting, invitationfor sharing and emphasis that personal requests willbe transformed to a general topic. The therapeuticapproach is based on integrating psychodynamicunderstanding with a crisis intervention modelwhose basic principles include facilitating under-standing, mobilizing resources for stabilization andfocusing on problem solving [16]. The nonstructuredelement encourages sharing concerns regardinghospitalization, therapy and general coping. Themeeting’s closing statement stresses the importancethat staff sees in the meeting as part of effectivecoping. After each meeting, the staff meets for20min to share understandings from the meeting.The Ethical Committee of the hospital wasnotified of this work and gave formal approvalfor its publication. Topics discussed in radiotherapy CM From our experience over the past 3 years of conducting the CM in the Radiotherapy Depart-ment, we can outline common topics that ariseduring the meetings. Patients’ topics Patients raise issues relating to daily life in thedepartment, such as discontent about services(noise, hygiene, etc.) and communication difficul-ties with staff. Information is requested regardingcancer, treatments, discharge, social benefits andpsychological support. Emotional expression isencouraged. The CM provides an opportunity forpatient interactions, often sharing advice onvarious coping methods. When discontent isexpressed, immediate facilitation shifts the inter-personal conflict to terminology of coping styles. Family members’ issues Caregivers express distress about lack of access tophysicians and communication difficulties with thepatient. Caregivers share their loneliness, frustra-tion, anxieties and cultural differences regardinghospitalization and perspectives on end-of-life. Staff involvement Staff answers questions regarding treatments andexplains department policies. Staff may expressown feelings and convey empathic understanding.The staff meeting at the end of CM enables clinicalscreening of distress and helps to re-examinedepartment policies, procedures and expectations.The CM enhances staff collaboration and is animportant managerial tool for the head physicianand head nurse. Facilitator aspects Facilitation follows a combination of an ‘Inductiveand Interactive facilitation style’ [14] by promotingan open discussion integrated with active anddidactic facilitation, based on stages of a crisisintervention model and integrated with psychody-namic understanding. Process and content aremonitored, moving from the concrete (complaintsabout food quality) to a more symbolic level(displacement of negative feelings). Emotionalexpression is encouraged as part of an adaptivecoping mode. The facilitator identifies extrememodes of splitting (i.e. ‘good’–‘bad’) and bridgesthe split immediately (i.e. anger at external agencieswhile praising the current staff). Interpersonalcommunication is encouraged but group dynamicsare not usually addressed. Case vignette—‘food for thought in CM’ The following illustrates how a topic progressesfrom the concrete to the emotional and symbolic. Apatient opened a meeting by expressing disgustabout the deteriorating quality of food. Otherpatients joined her and the group tone was angry. Copyright r 2010 John Wiley & Sons, Ltd.  Psycho-Oncology   20 : 1126–1129 (2011) DOI : 10.1002/pon Oncology patient–family–staff community meeting 1127  The head nurse acknowledged the complaints andsuggested checking this issue with the hospitalkitchen head. The physician suggested that foodbecomes an issue in illness. Another patientexplained that eating has become an effort for hercompared with when she was healthy. The tone of discussion became quieter. The facilitator reflectedthe frustration and another patient explained thatfood received so much importance because therewere so few moments of satisfaction duringhospitalization. Some participants agreed and thetone became sad and reflective. The discussionshifted to coping with appetite issues. Discussion CM’s clinical contribution Our subjective impression points to the CM’spositive impact on promoting open communica-tions and interpersonal connections, enablingemotional ventilation and providing access toprofessional information. These outcomes contri-bute to lessening patient and family burdens andenhance the perceived and actual quality of care[4,5]. In addition, the CM enables staff to learn of treatment complications, special needs or distress.Staff observations regarding efficacy are discussedat the staff meetings at the end of the CM. CM’s contribution to open communication The CM provides direct and open communicationwith staff. A major achievement is noted whenmembers overcome fears of retaliation and expressdiscontent toward staff. The participation of aphysician is vital for the success of the meeting byanswering the need for access to medical staff [4,5]and this also helps in recruitment for each meeting.The participation of senior staff emphasizes thatopen communication is vital for effective copingand palliative treatment [6].The CM is a unique method for discussing thedynamics of ‘double concealment’ (i.e. both patientand family conceal information for fear of harm),which may lead to lack of communication, lone-liness and difficulty in beginning the grievingprocess [17]. It provides a special opportunity todiscuss dilemmas as an effective coping strategy[18]. The CM enables caregivers to express theirown distress which is often set aside, thus switchingroles with patients and seeking care and recogni-tion of their distress.On an interpersonal level, the CM provides fornew social interactions; veteran patients share theirknowledge and encourage newcomers, promotingempowerment of patients who initiate variousactivities (e.g. inviting others to recreationalactivities). The participation of patients atvarying stages of illness is often challenging butheterogeneity has its benefits. For example, apatient at terminal stage may share fear of death.This may stir anxiety among other patients, but itenables the open talk of unspoken fears that areshared by all participants (including staff).The discussion is stopped by the facilitator atvarious times for translation. This is often time-consuming but, on the whole, participants acceptand even request translation. We assume that thisis due to the great need for comprehension [19]during hospitalization. Radiotherapy CM versus psychiatric CM The Psychiatric CM excludes family members,while inclusion of family members in the Radio-therapy Department was based on the essential andpositive involvement of family caregivers in cancercare [20,21]. Additionally, in psychiatric settings,psychotherapeutic interactions and group therapyare primary methods of in-patient care [13].However, in Oncology settings, frequently bothstaff and patients are less acquainted withpsychotherapy and, for many participants, theCM is their first encounter with psychotherapeuticintervention. CM’s influence on department procedures and staff  The CM has become an important departmentalmanagerial tool by clarifying procedures, imple-menting suggestions for improvements (e.g. im-proving information flow), and re-examiningdepartment policies (i.e. complaints of late nightvisitors). The staff, too, has learned the importanceof setting time aside for sharing as a model of effective coping and has greater acceptance of psychological dynamics. This may help combatthe depersonalization factor and improve commu-nication skills which were found as contributing tostaff burnout [22]. Conclusions To the best of our knowledge, this is the first timethat the CM has been introduced to a generalhospital in-patient setting, thereby providing aunique and innovative therapeutic intervention. Itseems that the CM provides the in-patient depart-ment with a means of answering the need for opencommunication, empathic interactions and theenhanced perception of quality of care. We assumethat this contributes to the growing demandfor a holistic approach in cancer care. A structuredstudy is needed to substantiate these descriptiveoutcomes. 1128 L. Eliasov  et al. Copyright r 2010 John Wiley & Sons, Ltd.  Psycho-Oncology   20 : 1126–1129 (2011) DOI : 10.1002/pon  References 1. Spiegel D, Giese-Davis J. Depression and cancer:mechanisms and disease progression.  Biol Psychiatry 2003; 54 :269–282.2. Fritzsche K, Liptai C, Henke M. Psychosocial distressand need for psychotherapeutic treatment in cancerpatients undergoing radiotherapy.  Radiother Oncol  2004; 72 :183–189.3. Heaman M, Gupton A. Perceptions of bed rest bywomen with high-risk pregnancies: a comparisonbetween home and hospital.  Birth  1998; 25 :252–258.4. Davidson JE. Family-centered care: meeting the needsof patients’ families and helping families adapt tocritical illness.  Crit Care Nurse  2009; 29 :28–34.5. Rabow MW, Hauser JM, Adams J. Supporting familycaregivers at the end of life: ‘they don’t know what theydon’t know’.  J Am Med Assoc  2004; 291 :483–491.6. Hanson LC, Danis M, Garrett J. What is wrong withend-of-life care? Opinions of bereaved family members. J Am Geriatr Soc  1997; 45 :1339–1344.7. Rice CA. The community meeting. In  Group Therapy inClinical Practice  (Chapter 6). Alonso A, Swiller H (eds).American Psychiatric Press: Washington, DC, 1993.8. Kreeger L.  The Large Group :  Dynamics and Therapy .F. E. Peacok Publishers: Itasca, IL, 1975.9. Kibel HD. Diversity in the practice of inpatient grouppsychotherapy in North America.  Group Anal   1992; 25 :225–239.10. Spiegel D, Classen C.  Group Therapy for CancerPatients . Basic Books: New York, NY, 2000.11. Classen C, Butler LD, Koopman C  et al  . Supportive-expressive group therapy and distress in patients withmetastatic breast cancer: a randomized clinical inter-vention trial.  Arch Gen Psychiatry  2001; 58 :494–501.12. Goodwin PJ. Support groups in breast cancer: whena negative result is positive.  J Clin Oncol   2004; 22 :4244–4246.13. Klein RH, Brown SL. Large group processes andthe patient-staff community meeting.  Int J GroupPsychother  1987; 37 :219–237.14. Spira JL. Understanding and developing psychotherapygroups for medically ill patients. In  Group Therapy for Medically Ill Patients  (Chapter 1), Spira JL (ed.).The Guilford Press: New York, NY, 1997.15. Pines M. Overview. In  The Large Group :  Dynamics and Therapy , Kreeger L (ed.). F. E. Peacok Publishers:Itasca, IL, 1975.16. Flannery RB, Everly GS. Crisis intervention: a review. Int J Emerg Ment Health  2000; 2 :119–125.17. Eliasov L, Lulav-Grinwald D, Zalman D, Vorobeichik M,Halevi-Gurevich M. The Family Lounge—familyaspects of the community meeting in Radiotherapydepartment.  J Pediatr Hematol Oncol   2008; 30 :S1.18. Carroll KS. Family support groups for medically illpatients and their families. In  Group Therapy in Clinical Practice  (Chapter 11). Alonso A, Swiller H (eds).American Psychiatric Press: Washington, DC, 1993.19. Antonovsky, A.  Unraveling The Mystery of Health— How People Manage Stress and Stay Well  . Jossey-BassPublishers: San Francisco, 1987.20. Glajchen M. The emerging role and needs of familycaregivers in cancer care.  J Support Oncol   2004; 2 :145–155.21. Grunfeld E, Coyle D, Whelan T  et al  . Family caregiverburden: results of a longitudinal study of breast cancerpatients and their principal caregivers.  CMAJ   2004; 170 :1795–1801.22. Ramirez AJ, Graham J, Richards MA  et al  . Burnoutand psychiatric disorder among cancer clinicians.  Br J Cancer  1995; 71 :1263–1269. Oncology patient–family–staff community meeting 1129 Copyright r 2010 John Wiley & Sons, Ltd.  Psycho-Oncology   20 : 1126–1129 (2011) DOI : 10.1002/pon
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