How do you feel about cancer now?--survival and psychosocial support.

This study by Evans and Connis (Comparison of Brief Group Therapies for Depressed Cancer Patients, page 306) compares two types of group psychotherapy for depressed cancer patients who are also receiving radiation therapy. It contributes to a growing literature indicating that group psychotherapy is effective in helping cancer patients better cope with their disease. As the authors note, a number of studies have shown that group psychotherapy can help reduce anxiety and depression, decrease pain, and may even influence survival time (1). The Evans and Connis study is a second generation study in that it does not really address the question, "Does group psychotherapy work? " Rather, it provides a randomized comparison of two types of group therapy-one focusing on cognition and the other on social support and affective expression. This kind of systematic exploration of the types of intervention that are most effective is much needed in the field now. There is sufficient evidence that such treatments work. By itself that is no longer an interesting question. How they work is the next question. The authors call for process analysis, which would be helpful as well, but systematic comparison of different types of intervention is a useful contribution. The authors found that the support group method was more effective than cognitive behavioral treatment, although both were superior to the findings in the control group. In particular, it was only the social support group participants who showed significantly improved scores on somatization and depression, as well as global severity of distress, on the SCL-90-R. The authors speculate that the reason for this differential effectiveness was some possible stress induced by the cognitive behavioral method. Although this is possible, it may well be that emotional expression, a major component of the social support intervention employed by the authors, has a powerful and positive therapeutic effect. There is a literature suggesting that cancer patients are, if anything, rather emotionally suppressive (2-3) and that cancer patients who give vent to feelings do better medically (4). Whether or not cancer patients differ from others in this regard, there is reason to believe that the ability to express strong feelings in a supportive group setting would have positive therapeutic benefit. Expression of emotion has the potential to facilitate a shift from emotion-focused coping, in which the patient is simply trying to manage intense and unpleasant affect, to problemfocused coping, in which the discomfort is acknowledged but can lead to various means of addressing or even resolving some of the causes of the negative emotion. In our psychosocial treatment laboratory, we have obtained recent evidence that attempts to suppress emotion are counterproductive. Metastatic breast cancer patients who rated themselves as high in emotional suppression on the Courtauld Emotional Control Scale (5) turned out to have higher total mood disturbance scores on the Profile of Mood States (6) than those who were low in affect suppression. In other words, suppression of adverse affect does not work. It seems to increase, rather than reduce, dysphoria. The patient who suffers constant intrusion of her fear of death may be relieved by the opportunity to discuss that fear with others in a similar situation. As one support group member commented, "The world hasn't changed, but I feel less alone with my feelings about it. " It is indeed interesting that similar results were obtained in a study of cognitive behavioral versus supportive expressive group therapy for HIV infected individuals (7). In that study also, both interventions were helpful, but there was advantage for the supportive intervention. The fact that similar results are found in the treatment of two different groups of medically ill people suggests that the finding is a valid and robust one. Indeed, a sense of isolation, especially with uncomfortable affect, may compound disease-related anxiety and depression. Any cancer patient naturally fears death, even though many are cured of the disease. But, one way in which we conceptualize death is isolation (8). Death is the ultimate aloneness: removal from loved ones. Anything that makes