Group Sessions Details
Lewis Mehl-Madrona, MD, PhD
Session 1: Introduction to Group
Purpose: To introduce participants to the group sessions.
Procedure: Participants are given an outline for the formal group sessions. The goals of the group are defined, including: a) increasing the ability to relax during asthma attacks along with strategies to reduce severity of attack, developing better coping styles, improving social support. The Talking Circle, a traditional Native American group method in which an object is passed around the group, is described. Group members speak when they hold the object (usually a stick) without interruption until they are finished. Then the stick is passed to the next member until it passes around the entire circle. Participants are then asked to keep a journal of times of asthma attacks, respiratory functions, times and amounts of medication usage, visits to clinicians, along with information pertinent to the homework exercises that will be completed.
Session 2: Stress and Life Events
Purpose: To start patients’ understanding of the ups and downs of the stresses in their lives.
Procedure: We discussed what were stressful life events. Participants discussed their major stressors and how they felt. This became a stimulus for discussing the relationship between life’s ups and downs and the severity of asthma symptoms.
Guided-imagery exercise: Creating an inner landscape and exploring the territory of the lungs.
Homework: Participants were given Timeline Health History forms (available from the author) related to stress over time. They were taught how to use the forms to assign numbers and levels to their stress levels as they remembered them. Memory recall techniques were used such as reminding patients about holidays, specific events in their lives, anniversaries, and how they felt on each of those occasions.
Session 3: The Timeline Health History: Stress
Purpose: To start patients’ understanding of the ups and downs of the stresses in their lives (continued).
Procedure: Participants reviewed their stress levels from the Timeline History and discussed how they felt during these times of their lives. They looked at their overall cumulative levels of stress and their patterns for experiencing stress over the course of their lives. Participants shared the timelines of their life with the group. This became a stimulus for discussing the relationship between life’s ups and downs and the severity of asthma symptoms.
Guided-imagery exercise: Participants created a visual image for asthma as a creature.
Homework: Participants were given Timeline Health History forms related to social support and used them in the same manner regarding social support as was done for stress. Memory recall techniques were used again. Participants listed the levels of support from family, friends, and spouse that they remembered and what form this support took.
Session 4: The Timeline Health History: Social Support
Purpose: 1) To teach the idea of relying on others; 2) to teach the skills for selecting appropriate sources of social support; and 3) to provide a feeling of more social support and mastery even if none currently exists.
Procedure: Participants listed the people to whom they could turn for specific kinds of help, along with the pros and cons of receiving help from that person. Patients were paired and reviewed each other’s lists. They assisted each other to name the help they needed most and the help they were most able to give. These were written on index cards, taped to the wall, and patients were matched to help each other when possible. A guided-imagery/visualization exercise facilitated each patient’s imagining s/he had all the help needed, seeing him or herself developing new sources of support. Feeling comfortable, relaxed, and secure was emphasized.
Guided-imagery exercise: Participants explored the origins of asthma by journeying up the river of their lives to a time before the asthma began. Then they journeyed down river, watching the first seed of the asthma be planted, and watching that plant grow into a full-blown disease, including how it was fed and watered; how the weeds were removed; who put the seed there in the first place. The plant transforms into an animal who is asked what it would take to make it leave, and what good it thinks it does for the person afflicted by the illness.
Session 5: Stress Reduction: How We Cope with Stress
Purpose: 1) To increase personal awareness of coping styles; and 2) to plant ideas of alternative styles of coping.
Exercise: Patients discussed how they coped with stress to stimulate discussion about coping. Once participants understood the concept of coping, patients presented situations they had experienced. Others described how they would have handled the situation. Alcohol, drugs, cigarettes, and eating were discussed as methods of coping. Participants were asked to recall a time when they coped with stress using alcohol, drugs, cigarettes, or food. An imagery/visualization exercise was done for patients to learn relaxation skills and meditation techniques. Participants were shown how to keep stress/coping diaries.
Guided-imagery exercise: After relaxation and meditation, participants imagined all the choice points of their lives, focusing on the roads they didn’t take and where those versions of themselves ended up. How are those versions of themselves different?
Homework: Participants were asked to keep stress/coping diaries for the following week to discuss at the next session.
Session 6: Coping with Stress II
Purpose: 1) To increase personal awareness of coping styles; and 2) to plant ideas of alternative styles of coping (continued).
Exercise: Stress/coping diaries were reviewed for the preceding week and were discussed. A further visualization exercise was provided for teaching relaxation/coping skills. Participants were each given an audiotape copy of the exercise for home listening.
Homework: Nightly listening to the audiotape plus keeping a seven-day diet diary.
Session 7: Alcohol, Drugs, Sugar, Fat, and Food
Goals: 1) To increase awareness about the use of substances as coping strategies; 2) to develop alternatives to using food, sugar, alcohol, and drugs as coping mechanisms; and 3) to increase a sense of personal control over substance use.
Exercise: Diet diaries were discussed in relation to stressful occurrences during the week. The timeline for alcohol, drugs, caffeine, and diet (short- and long-term) was administered and discussed. A visualization/self-hypnosis session was provided (with audiotape for home listening).
Session 8: Increasing Emotional Awareness
Purpose: To increase participants’ level of emotional awareness.
Exercise: Portable biofeedback devices were distributed. The group was broken into paired subgroups to ask each other structured questions and listen to the other’s response in skin conductance, calling attention to dramatic changes. One person volunteered to speak with the reassembled group with physiologic monitoring devices attached.
Session 9: Environmental Awareness
Goals: To provide patients with awareness of negative factors related to social desirability that might drive them toward behavior that will worsen their diabetes.
Exercise: Discussion of the times we do things because we want to look good vs when we do things because it’s the socially desirable thing to do, even if it is not in the best interest of our health. Visualization exercises were done to facilitate a sense of personal responsibility. Small group role-playing exercises of social desirability tasks were done.
Session 10: Health Beliefs
Goals: To provide patients with awareness of negative factors related to health beliefs that might drive them toward behavior that will worsen their diabetes. For example, believing in the inevitability of complications might produce a laissez-faire attitude toward their prevention.
Exercise: Cognitive therapy tools were used to help participants change beliefs detrimental to health behavior. A visualization exercise concluded this session.
Session 11: Social Functioning I
Goals: To provide patients with opportunities to increase their level of social functioning in daily life, thereby increasing a sense of control and mastery.
Exercise: Participants discussed each other’s areas of difficulty in social functioning. Participants’ areas of needs were assessed during this session in preparation for specific behavioral skills training exercises pertinent to those areas of weakness in Session 12.
Session 12: Social Functioning II
Goals: To provide patients with opportunities to increase their level of social functioning in daily life, thereby increasing a sense of control and mastery (continued).
Exercise: Specific social skills training exercises were provided on the basis of assessments done in Session 11.
Session 13: Coping Skills I
Goals: To provide patients with increased skills in visualization to use at home.
Exercise: Visualization exercises were conducted to increase skills of participants to use these techniques after the conclusion of the group. Audiotapes were made. Brief discussions of rigidity were made with suggestions for increasing flexibility.
Session 14: Coping Skills 2
Goals: To provide patients with increased skills in visualization to use at home (continued).
Exercise: Visualization exercises were conducted to increase skills of participants to use these techniques after the conclusion of the group. Audiotapes were made. Discussions of self-esteem and suggestions within the exercise for increased self-esteem occurred.
Session 15: Family Influences I
Goals: 1) To involve family members in the group process; 2) to prepare family members for sharing with participants what has been accomplished; 3) large group family therapy.
Exercise: Large Group Family Therapy.
Feedback: Before the group finished, there was a discussion of self-esteem within the context of the family and its relationship to asthma symptoms.
Session 16: Family Influences II
Goals: 1) To involve family members in the group process; 2) to prepare family members for sharing with participants what has been accomplished; 3) large group family therapy (continued).
Exercise: Large Group Family Therapy.
Feedback: We wished to stimulate discussions of the role of family relationships and conflict to asthma symptoms.
Homework: Visualization practice using audiotape made during the group.
~~~~~~~~~~~~~
Session 17: Evaluation of Previous Sessions
Goals: Negotiation of contract to continue working together.
Exercise: None planned. General discussion took the place of participants’ feelings about being in the group. Feedback for the leaders was solicited.
Session 18: What Character, What Story
Goals: To explore narrative approaches to better understand the lives we are living.
Exercise: We begin with a guided-imagery exercise in which participants are invited to view their lives as a play, a story, or a novel, and to wonder what character and what plot they are living. After the exercise, we also considered to what characters and to what stories (from movies, plays, books, or even comics and cartoons) we have been most attracted. We used the results of these exercises to think about how we might want to change our lives.
Session 19: Preferred Story
Goals: To explore who we want to be.
Exercises: We used guided imagery to start the group and explored our dreams of who we wish to be. We looked at the characters from movies, television, literature, or comics that we most admire and want to emulate. We compared our most-admired characters to the characters we think are most like us and considered the gap between how we see ourselves and who we wish to be. We brainstormed about how to close that gap.
Session 20: Possible Futures
Goals: To explore the futures we wish to create.
Exercises: We used guided imagery to create stories about possible futures that we could have. The exercise looked for the best possible future, an average future, and the worst possible future. We saw through imagery how asthma changes in each of these three futures. We used techniques for dialogue with our future selves.
Session 21: Family Heritage
Goals: To explore our families and their illnesses and strengths.
Exercises: We built upon previous family exercises to create a genealogy of asthma and other illnesses as well as stories that people lived and characters that they most resemble. We looked at the broad family as a play unfolding over time.
Session 22: Family Reconstruction I
Goals: To understand how family in the past continues to affect our present and future.
Exercises: Family reconstruction is a technique in which people enroll other group members to help them act out stories from the family’s past. These stories could originate in this life or even in previous centuries. Group members are assigned roles and perform those roles to enact a play of the family’s past.
Session 23: Family Reconstruction II
Goals: To understand how family in the past continues to affect our present and future (continued).
Exercise: Continuation of Session 22 for remaining group members.
Session 24: Wrap-Up
Goals: Evaluate the group and get feedback for changing future groups.
Exercises: We used The Talking Circle format to get feedback from group members and to get ideas about what we could do differently or better.
