Psychological Intervention for Women

THEORY

Psycho-Spiritual Integrative Therapy: Psychological Intervention for Women

With Breast Cancer

Diana Corwin Palo Alto University

Kathleen Wall Institute of Transpersonal Psychology

Cheryl Koopman Stanford University

Women with breast cancer frequently report psychological distress throughout the treatment process. Patients have several empirically supported options for group psychotherapy while undergoing breast cancer treatment. However, few interven- tions have been developed that incorporate spirituality into psychotherapy, despite indications that patients desire such treatment. Psycho-Spiritual Integrative Ther- apy (PSIT) incorporates principles of third-wave Cognitive Behavioral Therapy, mindfulness, and passage meditation to provide women with breast cancer with an intervention that addresses both psychological and spiritual needs. Preliminary research suggests that PSIT is associated with improved quality of life, mood, and physical, psychological, and spiritual well-being in women with breast cancer.

Keywords: breast cancer; group intervention; spirituality

In 2007, for every 100,000 women in the United States, 126.3 were diagnosed with breast cancer (Altekruse et al., 2010). In 2010, there were 209,060 new cases of breast cancer diagnosed—mostly among women—207,090, but also including 1,970 among men (American Can- cer Society, 2010). Although group psychotherapy interventions have been shown to be effective for women with breast cancer, many women

Manuscript submitted January 14, 2011; final revision accepted March 8, 2012. Diana Corwin, B.A., is a graduate student in the PGSP-Stanford Psy.D. Consortium, Palo Alto University. Kathleen Wall, Ph.D., is an associate professor with the Institute of Transpersonal Psychology, Palo Alto, California. Cheryl Koopman, Ph.D., is a professor in the Department of Psychiatry and Behavioral Sciences, Stanford University. The authors wish to express our gratitude to Alexandra Aylward, B.A., for her contributions to this work. This research was funded by the Lloyd Symington Foun- dation. Correspondence concerning this article should be addressed to Cheryl Koopman, Department of Psychiatry and Behavioral Sciences, Stanford University, MC: 5718, Stanford, CA 94305-5718. E-mail: koopman@stanford.edu

THE JOURNAL FOR SPECIALISTS IN GROUP WORK, Vol. 37 No. 3, September 2012, 252–273

DOI: 10.1080/01933922.2012.686961

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do not utilize these interventions during the course of breast cancer treat- ment. This article describes a novel intervention for women with breast cancer—Psycho-Spiritual Integrative Therapy (PSIT), which incorpo- rates spirituality into psychological treatment. PSIT utilizes third-wave Cognitive Behavioral Therapy (CBT), mindfulness, and passage medi- tation to improve mood and quality of life in women with breast cancer.

Three factors underscore the need for interventions that incorporate spirituality into psychological treatment: (a) the psychological and physical sequelae of breast cancer; (b) evidence of the efficacy of avail- able psychological interventions for women with breast cancer; and (c) research on the importance of spirituality in psychological recovery from this illness. Following a brief review of these factors, we will review recent interventions that integrate spirituality into psychological treatment, with an emphasis on describing and reviewing preliminary empirical support for PSIT.

PSYCHOLOGICAL AND PHYSICAL SEQUELAE OF BREAST CANCER

Studies have suggested that across the trajectory of the illness, the incidence of emotional distress among cancer patients in North America ranges from 35 to 45%; from the diagnosis stage to the survivorship stage, patients are at risk for developing depression, posttraumatic stress disorder (PTSD), and anxiety (Bultz & Carlson, 2006; Carlson, Speca, Patel, & Goodey, 2004; Cordova et al., 1995; Koopman et al., 2001; Zabora, Brintzenhofeszoc, Curbow, Hooker, & Piantadosi, 2001). Patients of all ages and ethnicities expressed fears about cancer recur- rence, pain, suffering, and death, and reported that they felt an ongoing need for emotional and practical support from family and friends, access to professional counselors, and a need to learn coping strategies so they could deal with their fears and manage day-to-day stress (Ashing-Giwa et al., 2004; Thewes, Buttow, Girgis, & Pendlebury, 2004). Symptoms of depression, PTSD, and other psychological distress make dealing with the diagnosis and treatment of breast cancer difficult. Successful man- agement of the distressing emotions that accompany a diagnosis of breast cancer can lead to improved medical and psychosocial results (Carlson, Speca, Faris, & Patel, 2007; Ozer & Bandura, 1990).

PSYCHOTHERAPY FOR PATIENTS WITH CANCER

Receiving psychosocial services is becoming the standard practice for cancer patients (Dreher, 1997) A meta-analysis of psychosocial

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interventions for breast cancer found that group psychotherapy is more effective than individual psychotherapy in reducing affective symptoms in breast cancer patients (Naaman, Radwan, Fergusson, & Johnson, 2009). Group psychotherapy interventions are effective in reducing depression, pain, distress, and hopelessness and improv- ing mood, self-esteem, and social support in patients with chronic ill- ness, including women with breast cancer (Goldstein & Frantsve, 2009).

Group psychotherapy interventions are moderately effective in improving quality of life and reducing psychological distress in cancer patients (Newell, Sanson-Fisher, & Savolainen, 2002). Female breast cancer patients exhibited gains in physical, cognitive, social, and emotional functioning following a group psychosocial intervention; these gains were most prominent in participants who had poor quality of life prior to treatment (Hong, Wang, Mei, Zhang, & Tang, 2010). Group psychotherapy for women with breast cancer and comorbid affective disorders effectively reduces psychopathology and affective symptoms (Grassi, Sabato, Rossi, Marmai, & Biancosino, 2009). Untreated depression has been linked to shorter survival times, poss- ibly due to poorer adherence to treatment; group therapy prevents and treats depression in breast cancer patients (Kissane, 2009). Despite the efficacy of psychosocial interventions, only 26–30% of patients utilize these services, and minority patients are especially underrepre- sented in service utilization (Ganz et al., 2002; Gottlieb & Wachala, 2007; Owen, Goldstein, Lee, Breen, & Rowland, 2007). One possible reason patients may underutilize current resources is the lack of emphasis on spirituality in current psychosocial interventions. PSIT aims to address this underutilization issue by appealing to patients seeking a psychological intervention that incorporates spirituality.

THE IMPORTANCE OF SPIRITUALITY IN PSYCHOSOCIAL TREATMENT FOR CANCER

Diagnosis and treatment for cancer can be a traumatic event for some patients (Tomich & Helgeson, 2002), with consequent distress lasting for several years post-treatment (Cordova & Andrykowski, 2003). Theory and research on adjustment to trauma suggest that basic global assumptions about one’s self and the world are violated, such as beliefs that the world is a meaningful, comprehensible, and just place (Park, Edmondson, Fenster, & Blank, 2008). Global beliefs are schemas through which one can organize information about the meaning of life; often these schemas are spiritual in nature (Park, 2005, 2007).

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Park explains the potent and multidimensional influences of religi- on and spirituality on individual health and well-being by conceptua- lizing spirituality as a meaning-making perspective (2007). Because most religions provide an integrated set of beliefs, aspirations, and guidelines for living, individuals can perceive, understand, evaluate, organize, and direct their behavior (Park, 2007). Spirituality can pro- vide a framework in which to develop and understand one’s life pur- pose and to interpret significant life events, such as a cancer diagnosis.

Spirituality is increasingly being recognized as an essential compo- nent of health and well-being by cancer physicians, researchers, and mental health practitioners (Aukst-Margetic et al., 2005; Cotton, Levine, Fitzpatric, Dold, & Targ, 1999; Lin & Bauer-Wu, 2003; McClain, Rosenfield, & Breitbart, 2003; Yanez et al., 2009). However, research conducted on spiritually based interventions is sparse, and many psychosocial interventions for cancer do not address spirituality. Researchers have found that, on average, more than half of cancer patients view religion=spirituality as personally important and experi- ence spiritual needs (Balboni et al., 2007; Jenkins & Pargament 1995; Thuné-Boyle, Stygall, Keshtgar, & Newman, 2006). In qualitative research, cancer patients often spontaneously mentioned that they found that spirituality was important in dealing with their cancer (Flannelly, Flannelly, & Weaver, 2002). Furthermore, a study focusing on female breast cancer survivors found that 85% reported that spiri- tuality was an important part of their lives (Bloom, Kang, Petersen, & Stewart, 2007).

Ethnically diverse (Black and Hispanic) patients, in particular, report a desire for spiritual interventions that is unmet by many cur- rently used psychological treatments for cancer (Moadel et al., 1999). In their ethnically diverse urban study of cancer patients, Moadel and colleagues (1999) found that patients said they wanted help with overcoming fears (51%); finding hope (42%); finding meaning in life (40%); finding spiritual resources (39%); and having someone to talk to about peace of mind (43%); the meaning of life (28%); and death and dying (25%). Taylor (2003) identified multiple spiritual needs of patients with cancer and family caregiver, including the need to review beliefs and the need to find meaning.

Several cross-sectional studies found that spirituality among cancer patients was related to a better quality of life and to positive moods (Brady, Peterman, Fitchett, Mo, & Cella, 1999; Rippentrop, Altmaier, & Burns, 2006; Yanez et al., 2009). Regardless of the patient’s percep- tion and appraisal of life threat, spirituality has been associated with reduced symptoms of distress in cancer patients (Laubmeier, Zakowski, & Bair, 2004). Cancer patients who report that their spiri- tual needs are addressed and supported in treatment also report an

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improved quality of life (Balboni et al., 2007). In one study, spiritual support from the medical team and pastoral visits were associated with higher quality of life scores near death (Balboni et al., 2010). In addition, spirituality was positively correlated with overall quality of life in African American women breast cancer survivors (Leak, Hu, & King, 2008) and Latina women breast cancer survivors (Wildes, Miller, San Miguel de Majors, & Ramirez, 2009).

Despite evidence that patients may benefit from and desire inter- ventions addressing spirituality, few interventions have been estab- lished that integrate both psychological and spiritual needs for individuals with cancer. One large study (N¼ 181) investigated the integration of spirituality into a Complementary and Alternative Medicine (CAM) treatment; the study found no statistical difference in the effects of the CAM and the comparison group, but both were associated with improving quality of life and spiritual well-being and decreasing depression (Targ & Levine, 2002). However, participants in the CAM group scored significantly higher on spiritual integration measures, including the experience of connectedness, intrinsic trust, and spiritual growth; the researchers further found that spiritual inte- gration was highly correlated with quality of life and positive mood.

The CAM differed significantly from PSIT in that it did not focus on pursuing one’s purpose in life, which is a central focus of PSIT. To date, we found only four other published studies that have inves- tigated interventions that integrate spirituality into psychological support for cancer patients (Breitbart, 2002; Cole, 2005; Cole & Pargament, 1999; Greenstein, 2000; Kristeller, Rhodes, Cripe, & Sheets, 2005). These studies indicate that spiritually oriented psycho- logical support is effective in breast cancer patients, but more research is needed to establish whether spiritually oriented interventions are equally or more effective than traditional interventions in this population.

There are several reasons a therapy that incorporates spirituality into treatment, such as PSIT, should be useful for cancer survivors. First, in the U.S. population, 95% believe in God (Gallup, 2002), and most people report that spiritual beliefs give them meaning and purpose in life and a framework that helps them cope with stressors (Oman & Thoresen, 2003). Furthermore, finding meaning and purpose in life after cancer is related to improved quality of life (Jim, Richardson, Golden-Kreutz, & Anderson, 2006; Park, et al., 2008; Tomich & Helge- son, 2002; Whitford & Olver, 2011), while continuing to search for but not find meaning 5 years after cancer is related to a declining quality of life (Tomich & Helgeson, 2002). Second, many cancer survivors endorse having spirituality addressed in their health care (Moadel et al., 1999). Third, a growing body of research links spirituality to

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improving quality of life and healthier immune functioning amongst cancer survivors and others with chronic illness (Breitbart, Gibson, Pop- pito, & Berg, 2004; Levine & Targ, 2002; Park et al., 2008; Sephton, Koopman, Schaal, Thoresen, & Spiegel, 2001; Tomich & Helgeson, 2002; Whitford, 2011; Yanez et al., 2009). Whitford and Olver (2011) found that two aspects of spirituality were particularly associated with quality of life among cancer patients—meaning and peace. PSIT directly addresses these issues of spirituality associated with quality of life by helping participants to clarify and move toward attaining their purpose in life and also by providing skills thatmay be used in daily life to experi- ence a sense of peace.

THEORETICAL AND EMPIRICAL UNDERPINNINGS OF PSIT

PSIT is a new psychotherapy that has been developed by Kathleen Wall and Carl Peters over the past two decades. PSIT was designed to help bridge a gap in mental health care for cancer patients by provid- ing psychosocial treatment that addresses spiritual concerns. PSIT aims to serve an underserved population of individuals by integrating spirituality into traditional psychosocial treatment. It is informed by stress and coping theory (Lazarus & Folkman, 1984; Park & Folkman, 1997), spiritual=religious coping (Miovic, 2004; Pargament, 1997), mindfulness (Carlson, Speca, Patel, & Goodey, 2003; Carlson et al., 2007; Kabat-Zinn, 2003), and elements of third wave behavioral thera- pies, especially Acceptance and Commitment Therapy (ACT) (Hayes, 2004; Hayes, Follette, & Linehan, 2004). The therapy encourages an exploration of a personal sense of spirituality for coping and enriching the individual’s life purpose, as has been recommended by others (Emmons, Kolby, & Kaiser, 1998; Miller, 1999). PSIT is non-doctrinal, relying on the individual’s sense of the sacred and spiritual beliefs; therefore it is suitable to people from most spiritual=religions traditions.

There is no universally accepted definition of spirituality. In PSIT spirituality is defined as a subjective experience of the sacred however the individual apprehends it (James, 1936). The emphasis on a person- ally defined sense of sacred allows for people of any spiritual=religious tradition or none to engage with whatever they consider sacred. For those with no religious belief system, this sense of the sacred might be a felt connection with nature, a universal order, or a humanistic perspective. A variety of aspects of spirituality are addressed in PSIT. These include the individual’s unique higher purpose of life, meaning, a deep sense of connection with the sacred, a sense of peace, and

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compassionate acceptance. Also the broader concept of spirituality is addressed in PSIT as a ‘‘personal search for meaning and purpose in life, connection with the transcendent dimension of existence, and the experience and feelings associated with that search . . . ’’ (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002).

The aims of this therapy include actualizing the patient’s highest life purpose and improving the patient’s quality of life. Practices of meditation and stress reduction facilitate the therapeutic process and provide specific skills to promote improved physical and psycho- logical quality of life. The process of PSIT begins with clarifying one’s life purpose, which for many people is spiritual (Emmons et al., 1998; Park & Folkman, 1997). Practice of mindful acceptance (MBSR and ACT) and psychological ‘‘working through’’ will enable patients to accept and transform the personal attributes that help and hinder the actualization of their life purpose. Additionally, the practice of receptivity to a personal sense of the sacred is encouraged to facilitate equanimity and to reinforce a commitment to living the individually defined purposeful life. PSIT also utilizes values clarification work, similar to ACT, to increase active coping, emotion regulation, and mindful awareness and acceptance (Garland, Gaylord, & Park, 2009).

PSIT teaches specific meditation and stress management skills to facilitate the therapy process and to provide symptom relief to essen- tially improve quality of life. Training in Mindfulness Based Stress Reduction (MBSR) encourages a non-judgmental accepting and wit- nessing of both the internal experiences (i.e., sensations, cognitions and emotions) and the personal patterns that help or hinder the actualization of the life purpose (Kabat-Zinn, 2003). Incorporation of passage meditation (Flinders, Oman, & Flinders, 2007) primes person- ally relevant spiritual experiences (Miller, 1999). Drawing on these experiences attenuates attachments and creates more flexibility in personal patterns. Hayes has suggested that this can ultimately lead to a commitment and action toward fulfillment of the patient’s self-selected life purpose (2004).

Meditation skills are helpful in developing specific practices to replace ruminations about cancer recurrence or physical disabilities as well as emotional distress and can serve to change the perception of distressing thoughts and emotions. Meditation in PSIT is acceptable to people from any spiritual tradition, including mainline organized religion, or those with no religious affiliation. The initial meditations, taught through MBSR, are presented as secular exercises, helpful in stress reduction and emotional regulation. These are applied in devel- opment of detached equanimity rather than reactivity when faced with the myriad stressors of cancer treatment and life. Passage

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meditation encourages participants to utilize short passages from any spiritual tradition or a secular poem or song representing the sacred to the individual.

Some of the specific skills taught in the PSIT intervention—includ- ing stress reduction, meditation, acceptance, MBSR and passage medi- tation—have been demonstrated to be helpful for patients with cancer and chronic stress (Astin et al., 1999; Carlson, Ursuliak, Goodey, Angen, & Speca, 2001; Oman, Hedberg, & Thoresen, 2006; Speca, Carlson, Goodey, & Angen, 2000). However, to our knowledge, no previous intervention has combined all of these elements into an integrated psychosocial intervention.

PSIT provides patients with a set of skills that patients can use repeatedly after completion of the intervention to cope with future stressors and to maintain gains in quality of life (Garlick, Wall, Cor- win, & Koopman, 2011; Ma & Teasdale, 2004). The goal of this inter- vention is to place the cancer experience and recovery into a larger context of providing an opportunity to revitalize one’s larger purpose in life and to develop skills and internal and spiritual resources for future coping. PSIT is novel in its emphasis on bolstering a patient’s capacities for coping—not only specifically with cancer as a potential threat—but also with cancer as a turning point to pursue larger life meanings, including pursuing one’s purpose in life.

PRELIMINARY RESEARCH ON PSIT

The results of two recent qualitative studies using a combined thematic and grounded theory approach (McDonald, Wall, Corwin, & Koopman, 2012; Rosequist, Wall, Corwin, Achterberg, & Koopman, 2012) suggest that the PSIT group intervention supports coping efforts and promotes self-acceptance, life purpose and meaning, spirituality, and a reassessment of values and priorities. These previous studies were conducted after obtaining approval of their ethical treatment of human subjects from the appropriate Institutional Review Board (IRB). This IRB approval permits us to report participants’ comments about their experiences in the group, while we keep participants’ iden- tities confidential. PSIT facilitates active acceptance, which may lower stress levels and lead to improved psychological adjustment (Rosequist et al., 2012). PSIT participants reported that participation in the intervention positively impacted their spiritual and existential development; this emphasis on existential development is one element of PSIT that may prepare participants for survivorship (McDonald et al., 2012). Many participants report that the experience in PSIT of observing their own thoughts, feelings, and behaviors with detached

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and nonjudgmental awareness enabled them to improve their inter- personal relationships (McDonald et al., 2012).

As described in a preliminary quantitative study (Garlick et al., 2011), no adverse events were reported throughout the course of the intervention in which 30 women with breast cancer participated. Fur- thermore, among 24 women who completed at least one follow-up assessment, significant improvements were found in women’s quality of life, as well as in reductions of overall mood disturbance and in mood states that include tension, depression anger, fatigue, and vigor (Garlick et al., 2011). The effect sizes for each measure ranged from small to large, with most greater than 0.31, the norm for psychosocial interventions with cancer populations (Rehse & Pukrop, 2003), and many of them in the range of 0.50 or greater, which has been desig- nated to indicate a clinically meaningful change (Cohen, 1988). Partici- pants exhibited statistically and clinically significant improvements in psychological, spiritual, and physical well-being (Garlick et al., 2011).

PSIT GROUP SESSIONS

PSIT includes eight weekly group sessions. These are summarized below and in Table 1. More details can be found in the participant workbook (Wall, 2010a) and the group leader manual (Wall, 2010b). Both are available by request.

As in most groups, PSIT is conducted in a small group with people sharing similar issues. In our PSIT research groups the common issue was cancer survivorship. Cohesiveness was quickly established. Part- icipants in PSIT reported the importance of the group as a major source of growth and a sense of community in two studies (McDonald et al., 2012; Rettger, 2011). A case example of PSIT is published else- where (Wall, Corwin, & Koopman, in press).

The PSIT group framework provides a supportive compassionate environment to explore deep personal meanings and one’s unique pur- pose in life. There are few settings in which these deep issues are explored therapeutically in a compassionate community. Group mem- bers work psychotherapeutically, sharing their experience of PSIT exercises such as clarifying life purpose and transforming helpful and hindering patterns to realizing that purpose. The sharing is a therapeutic experience, and serves as a powerful support and clarifi- cation and transformation. The group provides both a witnessing, which is therapeutic in most groups, and modeling of how others deal with these profound life issues.

Modeling is a common process in psychotherapeutic group frame- work. By seeing how others handle similar problems, the participants

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