A Cognitive Behavioral Therapy Group for Adolescent and Young Adult Cancer Patients: A Review of a Pilot Program

Participants

We offered a 6-week CBT therapy group to AYA cancer survivors aged 18 to 39. Group members were eligible to participate if they had a previous cancer diagnosis. No exclusions were made based on diagnosis or time since diagnosis. The therapy group was offered at an outpatient cancer institute that provides psychosocial and supportive services to adult cancer survivors. Four iterations of the 6-week group were delivered to AYAs with slight variations, with enrollment ranging from 2 to 6 participants per group. A total of 17 participants completed at least 1 group session, and 3 AYAs repeated participation in the 6-week group and attended more than 6 sessions. Of the remaining 14 AYAs, 3 attended 1 session, 4 attended 2 sessions, 3 attended 3 sessions, 2 attended 5 sessions, and 2 attended all 6 sessions.

AYAs were referred to the group from internal staff, such as social workers, nurse navigators, dietitians, genetic counselors, and exercise specialists, and also from local oncology clinics. An AYA nurse navigator who provides navigation services within the county emailed flyers to previously identified patients in the community. Flyers advertising the group were also posted within the cancer institute. Potential group members could also self-refer.

Group therapy providers

Each 6-week group was consistently led by a licensed psychologist (B.C.H.) and a psychology doctoral intern. The psychology doctoral interns were provided supervision in AYA services, group therapy, and CBT.

Intake process

The majority of group members received an intake interview before participation in group to provide basic education on the group format, assess current mental health problems, and address potential concerns about participating in a therapy group. Not all group members completed the intake process as they missed their intake appointment; however, due to the timeline of the group start date, they were not excluded from participating. Group members were informed that they were expected to attend five out of the six sessions to be able to participate; no other exclusion criteria were established.

CBT group structure and components

The structure of the CBT group was informed by research specific to common problems cancer survivors and AYAs face. Interventions were chosen based on their efficacy and rationale in the literature. Each group utilized the typical CBT structure of setting an agenda, reviewing homework, teaching a new skill, eliciting feedback, and assigning new homework. Topics included behavioral activation, relaxation techniques, cognitive restructuring, components of CBT-insomnia, and management of medical care (refer to Table 1 for detailed group structure and rationale).

Applicability of CBT group therapy to AYAs

All information obtained in the conclusions section was obtained through group leader observation and qualitative responses that group participants provided throughout group. Overall, our observations were that the proposed group outline provided good structure for group members to share personal experiences and learn new information. For example, group members “checked-in” with one another at the beginning of each session by reviewing their homework from the previous week. This model allowed for group cohesion and sharing of personal information in a structured way. During homework review, group members shared challenging situations from the previous week when they attempted to use the assigned skill. They discussed whether they used the skill and were successful; if they needed help, they would troubleshoot with other group members how to more effectively manage their problem.

In addition, interventions chosen were principle-driven in nature, thus, could be applied to a wide array of presenting problems. For example, group members were taught how to identify thoughts, emotions, behaviors, and physiological sensations, and they were instructed how to change behavior (behavioral activation), physiological sensations (progressive muscle relaxation), or thoughts (cognitive restructuring) to influence emotions. The skills were taught using common problematic thoughts that AYAs face, including thoughts related to cancer recurrence, appearance, or changes in independence. This approach was combined with more skill-specific interventions for sleep and management of medical care. Balancing a principle-based approach with problem-specific interventions not only addressed both the unique problems that AYAs face but also promoted generalization to more common mental health symptoms. Group member participation and engagement during sessions appeared high, potentially as a result of this model.

Although the CBT model allowed for practice of the newly learned skills between sessions, few group members routinely completed homework assignments between sessions. This is potentially problematic for an intervention-based group, as research indicates that completion of homework is directly related to increased improvements in outcomes. ¹⁶ These concerns were not widely addressed in the structure of the outlined group due to time limitations; however, the importance of homework completion could be reviewed more extensively in an individual intake or orientation session before the initiation of group.

Pros and cons to 6-week session and closed group format

The 6-week structure of group allowed sufficient time to introduce and practice new interventions in group. Group members were provided with sufficient information to begin practicing new skills, gauge if additional support was needed, and be able to enroll in individual therapy services to continue associated intervention.

However, some important themes that group members repeatedly expressed interest in were not covered explicitly in group due to time limitations. These areas included difficulties in sexual functioning, physical appearance, and general health behaviors. While these topics were discussed in the larger framework of cognitive restructuring and behavioral activation, specific interventions and psychoeducation may have been able to be provided if the group had additional sessions.

Regarding the closed group format, group members were able to receive ongoing support from a similar group of peers, and this provided stability and the opportunity for group cohesion. However, multiple group members participated in multiple iterations of the group. While group members may benefit from reiteration of skills, there are limitations to repeat participation. For example, group repeaters may be less engaged and committed as there are new group members and much of the reviewed material is redundant. However, they may benefit from ongoing peer support; a solution for group member completers could be to attend a once monthly “graduate” support group or group booster session.

The benefit of limiting exclusion criteria

By not restricting group membership by age or stage of treatment, group members were able to naturally learn from one another and provide practical advice and support to group members who were more recently diagnosed or entering into a new stage of survivorship. Therefore, a mentorship model naturally developed; however, even the “mentors” continued to receive support through skill development within the group. This format differs from other existing programs where “mentors” may be matched with a more novice survivor. The current group implementation promoted ongoing learning to survivors at any stage of the journey. This is important as research has demonstrated that AYA cancer survivors who have transitioned in to survivorship report a desire to receive support from other AYA survivors. ¹⁷ In addition, the current group did not make restrictons about type of diagnosis. There are limited numbers of AYAs in most clinics, and often there is an insufficient number of AYA referrals to create a disease-specific group or age-restricted group. Furthermore, group members learned about the variety of experiences of AYAs outside the scope of their specific diagnosis, which may have broadened their understanding of how peers are affected by cancer. Unless the group is psychoeducational in nature and designed for a specific disease process, the benefits of broadening the scope of referrals may outweigh making specifications that limit AYA patient inclusion.

Future directions

Limited research is available on the effectiveness of AYA group therapy to reduce psychological symptoms and cancer-related distress. This implementation project examined common dilemmas clinicians face in creating and initiating a therapy group, and it proposed a structure for a CBT therapy group that was successfully and repeatedly implemented with AYAs. Future research should examine clinical outcomes of AYAs who participate in the 6-week group and also assess unmet needs of group member completers. These results could be utilized to identify appropriate interventions to incorporate into the existing structure. In addition, a formal clinical trial could examine outcomes comparing a CBT-specific group to a more general support group for AYAs or another form of group psychotherapy. This information has important implications for staff utilization within cancer treatment centers, particularly when bandwidth is limited. Furthermore, implementing effective methods for reducing psychiatric symptoms may reduce the burden of these symptoms to the patient, the patient's psychosocial system, and the medical community.