Yonago Acta medica 2015;58:45–50

Original Article

Partnership in Psycho-Social Group Intervention for Cancer Patients: Factors toCreating Group Dynamics
Masami Chujo* and Hitoshi Okamura†*Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japanand †Department of Psychosocial Rehabilitation, Faculty of Health and Science, Graduate School, Hiroshima University, Hiroshima734-8553, Japan

cation on methods for coping with stress and for solving problems, group discussion and progressive muscle
relaxation (PMR). This positive effects of this approach
has also been verified in Japan.4, 5, 10Group interventions are not considered susceptible
to the skills of a therapist because a characteristic feature of intervention is that participants can understandeach others’ situations and support each other, i.e., they
participate in group dynamics.11 On the other hand, it
was reported that facilitators, who play a role in smoothand effective organization of group discussion in groupinterventions, provide their patients with intervention,
but have difficulty in, for example, managing participants with problems and feeling anxiety due to lack ofknowledge.12 This is thought to be because these facilitators and staff have more anxiety than necessary since
the mechanism for creating group dynamics in group interventions for Japanese cancer patients has not yet been
fully elucidated.
Based on the above background, we conducted astudy of a psycho-social intervention which was provento be useful for Japanese patients with primary and recurrent breast cancer.4 10 In this study, we investigatedin detail the factors that create group dynamics experienced by Japanese facilitators.

ABSTRACT
Background

The purpose of this study was to conduct a psycho-social group intervention consisting of 3
parts, educate patients on methods to cope with stressand solve problems, hold group discussions and practiceprogressive muscle relaxation (PMR) for cancer patients,
and investigate the way that group dynamics work in
psycho-social group interventions in Japan.
Methods Three facilitators and 2 sub-facilitators who
conducted the group intervention for breast cancer patients were qualitatively and inductively analyzed using
a phenomenological approach.
Results As a result, “hard effort,” “harmony of thewhole group” and “collaboration between therapists”
were extracted as the partnership functions of participants that work on the creation of group dynamics inpsycho-social group interventions. There was a structurein which “harmony of the whole group” and “collaboration between therapists” coexisted based on the basic
attitude of “hard effort.”
Conclusion It was considered that these 3 intervention
forms are involved in group dynamics in which participants can easily hold discussions, and are techniques
necessary for group intervention contributing to changes
in the psychological distress and the coping of participants.

SUBJECTS AND METHODS
Subjects

Facilitators and sub-facilitators: Eligible subjects
were facilitators of group interventions in cancer center
A or cancer center B who met the following criteria: i)experience as nurses for more than 5 years; ii) facilitator
training received in advance and iii) willingness to playa role in facilitating discussion among participants.

Key words group dynamics; group intervention; facili-tator; nurse; partnership
Recent advances in cancer treatment have helped breast
cancer patients live longer. However, breast cancer patients also have psychological burdens and therefore livewith psycho-social problems.1–3
Group therapy, which was developed in the UnitedStates and Europe as one of the psycho-social interventions for improving psychological distress and helping
cancer patients cope,4–9 is a program consisting of edu-

Group participants: Group participants were breast
cancer patients followed in cancer center A or cancer
center B who met the following eligibility criteria: i)adult women aged 20 years or older; ii) histological diagnosis of breast cancer and presence of histologically and/or clinically confirmed breast cancer; iii) no serious general condition; iv) no active double cancer; v) no clinicalneed for psychiatric treatment for depression, adjustment
disorder, etc. and vi) no difficulty in understanding theessence of the study.

Corresponding author: Masami Chujo, RN, PhD
chujo@med.tottori-u.ac.jp
Received 2014 December 19
Accepted 2015 January 23
Abbreviation: PMR, progressive muscle relaxation

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M. Chujo and H. Okamura

These patients were requested to participate in the
study from June 2002 to April 2003 in cancer center A
and from October 2006 to February 2008 in cancer center B.

ized the “real” world of the subject (reliability), whether
the study was conducted in the context considering theenvironment of the subject and all circumstances (meaning in the context), explanations and interpretations wereadequately given, and whether the results found in thisstudy could be applied to similar contexts or situations(transferability).

Intervention methods

This study employed a short-term (6-week) psychosocial group intervention, which had been verified to beeffective for Japanese patients with primary/recurrent
breast cancer.4, 10
A total of 6 weekly 90-min sessions of group intervention were given to a group of 3 to 8 participants.
Each session consisted of education on methods for coping with stress and for solving problems (20 min), discussion on coping (50 min) and learning about PMR (20min).

RESULTS
Characteristics of the subjects
An experienced facilitator: An experienced facilitator
had experience as a nurse for more than 10 years, had
experience of nursing breast cancer patients for morethan 3 years, had received facilitator training and had
experience as a facilitator of group interventions formore than 3 years.

Evaluation

New facilitators: Two new facilitators had experience
as nurses for more than 10 years on average and had received facilitator training. These facilitators operated a
6-session course for the first time.

Intervention scenes were recorded with a digital video
camera or IC recorder and later transcribed verbatim.
The original records were discarded after verbatim transcripts were made.

An experienced sub-facilitator: An experienced subfacilitator had experience as a nurse for more than 10
years, had experience of nursing breast cancer patientsfor more than 5 years, had received facilitator training
and had experience as a facilitator and sub-facilitator ofgroup interventions for more than 5 years.

Ethical considerations

After obtaining approval from the ethics committees of
the two research institutions and Fukuoka Prefectural
University, the outline of the study, voluntary nature ofparticipation and preservation of anonymity were explained verbally and in writing to the subjects and groupintervention participants, and their consent to participate
in the study was obtained.

A new sub-facilitator: A new sub-facilitator had experience of medical care for psycho-oncology and breast
cancer patients for 8 years and had received group facilitator training.

Analysis methods

For the analysis, we used a method to qualitatively andinductively extract factors creating group dynamics fromthe verbatim transcript data according to the purposeof the study, based on the concept of a phenomenological method.13 First, we repeatedly read the interview
descriptions to grasp the whole context, grouped similar
expressions, compared and investigated the relationships
among them, and named each group so that it represented a distinct meaning. We further reviewed the verbatim
transcripts many times to check whether the given groupnames reflected the true nature of the data. We further
grouped similar expressions, compared and investigated
the relationships among them. By repeating these procedures, we abstracted expressions gradually. Expressions,for which the true nature of meaning was captured, wereextracted as methods of the interventions used by facilitators.
In this process, we had discussions many times toimprove the reliability and validity of the study and toinvestigate whether the results were reliable and symbol-

A factor creating group dynamics during the groupintervention: As a result of the analysis, a core category“partnership” was extracted as a factor creating groupdynamics during the group intervention (Table 1). In addition, there were differences in subcategories between
experienced and new facilitators. Hereinafter, categories
are shown in “ ” and subcategories in < >, and interventions used by facilitators on which these extractions
were based in bold.
“Hard effort” This category means that facilitators worked
exceedingly hard to interact therapeutically with participants. Even when the facilitators could not make skillfulinterventions, their sincerity was expressed in emotions andconveyed to the participants. This category included 3 subcategories.
<Skillful interventions> This subcategory means that in intervention facilitators speculated what a participant intended
with his/her words and enhanced the feelings that he/she

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Partnership in group intervention
Table 1. Comparison of partnership between experienced and new facilitators
Core category Category

Subcategory in experienced facilitators

Subcategory in new facilitators

Partnership Hard effort				Harmony of
the whole group		Collaboration
between therapists

Skillful interventions
Interventions out of focus
Defense of the position of medical professionals
Watching over movements
Promotion of exchange
Enhancement of mutual support

Skillful interventions
Interventions out of focus
Defense of the position of medical professionals
Watching over movements
Promotion of exchange
Enhancement of mutual support

Role complementation

Need for support

attending physician in this discussion, I start to feel likeI can’t trust him or her because of that experience.”
Facilitator A: “Other situations like this also often occur inthis hospital, and many patients go through somethingsimilar. So when the doctor told you, ‘Let’s wait andsee,’ the doctor might not mean that he or she knew
was their cancer but would leave it alone.”wanted to convey so that the other participants could share
his/her feelings.
Participant 15: “The doctor came to me to collect blood saying, ‘I want to check your blood oxygen content,’ andstuck a needle into my artery, like this. It was very painful. The doctor said, ‘I am scared, too’ (laughing). ‘I am
scared, too’ (laughing). It was like a near-death experience.”
Participant 20: “I’m sorry to hear that. You really had a hard
time.”
Facilitator A: “I see. Your story . . . it was like you cameback alive.”
Participant 15: “When I thought about it later, it was . . .”“Harmony of the whole group” This category was also
common to both experienced and new facilitators and isnecessary for peaceful discussion among participants as thebasis on which group dynamics work among participants.
This category included 3 subcategories.
<Watching over movements> This subcategory means thatwhen discussion was active in a group, facilitators wouldn’t
dare to make active interventions.

<Interventions out of focus> This subcategory means thatfacilitators dealt with the superficial meanings of words indiscussion and failed to deal with the true meanings of thestory behind the words, or improperly focused on a topic
that a participant did not want the other participants to
know.

Participant 26: “Well, I would like to take a trip, first of all. I
will work harder for that and want to make an effort. After I began to come here, my anxiety went away a little
bit, or considerably. My anxiety, anxiety in my feelings,
has gone away completely.”
Participant 20: “(laughing) But you were anx. . .”Participant 26: “No! It was real . . . really!”
Participant 21: “You’ll be OK.”
Participant 20: “Thanks, I appreciate that.”
Participant 21: “You’ll be OK, because you’re a cheerfulperson. A lot of patients tend to be emotionally unbalanced . . . (omission).”Participant 26: “So, feelings are important. People say worry
is often the cause of illness.”
Participant 21: “In places like this . . .”Participant 26: “We have to chase our gloomy feelings
away.”

Participant 4: “When someone tells me ’You’re doing well,’I just think, huh. I’m a worth.”
Participant 2: “I cry, maybe because the tension I feel is released all of a sudden.”Participant 4: “I see.”
Facilitator A: “So . . . maybe you usually . . . make a strong
effort.”Participant 4: “I wouldn’t say I am making an effort like this(standing up firmly) . . . or maybe I do. I don’t know.”<Defense of the position of medical professionals> This
subcategory means that when medical services were criticized in the discussion, facilitators improperly explained thepresent state of, and/or defended, the medical services.

(The discussion continued as participants supported eachother, and Facilitator A felt no need to take part in orderto keep harmony in the group.)

Participant 22: “When I saw a doctor at another hospital,
a local hospital, I was told I had lung cancer and I wasreferred to this hospital. The doctor at the local hospital
told me, ‘The amount of cancer is no problem, at least
for a while, so let’s just leave things as they are.’ But I
insisted on getting some treatment and visited a pulmonologist, complaining of severe symptoms, and it was
finally found out that water had begun to accumulate in
my lungs. So, if I think about my relationship with the<Promotion of exchange> This subcategory means that facilitators took care so that all participants were able to takepart in a discussion.
Facilitator A: “Everyone has various problems. I think
everyone tries desperately to make an effort the firsttime . . . with various problems . . .”47

M. Chujo and H. Okamura

Participant 15: “That’s right. I really think so, too. I did notthink I would die of cancer the first time around.” (Participant 26 came in the room when Participant 15
was speaking)Participant 21: “Right! The first time around! But the second time . . . somehow . . . I don’t know yet. My point ofview has changed.”
Participant 15: “Right, but the first time around, I thought it[the cancer] was all gone.”
Participant 26: “Me, too. I thought it was all gone . . .”Participant 21: “The bad part of mine was resected, and I
thought it was all gone, too.”
Facilitator A: “Welcome Ms. 26. Thank you for coming.”(Everyone agreed)
Participant 26: “I’m sorry for interrupting. I had to worklate, but I thought I could finish work early today . . .
(omission)”things. I now have something like a [progress] scale andit encourages me (omission). I already think I’ve gotten
quite old, and I will not raise children any more (laughing). But, I think it is enough for me if I can live day byday.”
Facilitator A: “I think Ms. 3 is great because she has been
thinking positively from the beginning. It is important tohave positive thinking, but it is also important to face thepresent situation . . .”Sub-facilitator A: “I think positive thinking includes morethan hard effort.”
Participant 2: “At first, I thought I had to control myself inthat way and I had to be positive . . . which was like pressure. But I came to think I can sometimes be depressed,
and I came to think I don’t necessarily have to work hard
. . . (laughing)”<Need for support> This subcategory means that when a
new facilitator did not know how to talk to participants andhow to intervene, a sub-facilitator skillfully makes an intervention instead of the facilitator.

<Enhancement of mutual support> This subcategorymeans that in interventions, facilitators suggest that participants mutually express their feelings, share them and support each other, thereby making them all feel that they are
surviving together.

Facilitator B: “Well, let’s start the discussion. In previous
sessions, we talked about connections with people andsupport from people. Today’s theme is the relationshipwith attending physicians, families, friends and society.
I think sometimes you’re supported by these people
but sometimes you’re not. Everyone, please give youropinion on how to cope with problems when you are
not supported, or what to do when you cannot cope withproblems . . . or you can ask for advice . . .”Sub-facilitator B: (looking at the clock)
Facilitator B: (Facilitator B became aware that he/sheshould ask the participants whether they had time
to continue the session) “This session is originallyscheduled to end at 16:30. But, I would like to extend thediscussion for about 10 min. The session is scheduled to
end at 16:30, but I would like to continue the session until about 16:40. Is that OK for you? (the facilitator looks
at the sub-facilitator)
Sub-facilitator B: “Ms. 37 has to travel a long way.”
Facilitator B: “I see. Ms. 37, are you OK with that?”
Participant 37: “It’s OK for me. But we can’t really discuss
anything in only 10 min, can we?”Participant 16: “She was told, ‘You can take a trip again and
it is OK for you. If you undergo surgery soon, you will
be fine.’”Participant 8: “I see, but . . .”Participant 16: “But, I myself couldn’t think and my mind
went blank . . .”Participant 8: I’m just a parent . . . It is only talk. If you are
ill yourself like us, you would not to be sensitive.”
Facilitator A: “Well, this place is where you can shareyour feelings like this and consult with me or eachother.”
Participant 8: “That’s right.”“Collaboration between therapists” This category was
also common to both experienced and new facilitators andmeans that therapists, i.e., a facilitator and a sub-facilitatorin charge of education, collaborated so that group dynamics
could work between them. Two therapists recognized thedifferences between them and complemented each otherin their roles, which made the process of education and thediscussion go smoothly in the group interventions. This category included 2 subcategories.

DISCUSSION
A qualitative inductive analysis revealed that 3 factors
creating group dynamics, “hard effort,” “harmony of thewhole group” and “collaboration between therapists,” allcoexisted as [partnership]. In addition, these 3 categories
were observed in both experienced and new facilitators.
However, there were some differences in the content ofthese categories between new and experienced facilitators.
First, the category of “hard effort” included 3 subcategories, <skillful interventions>, <defense of the position of medical professionals> and <interventions out offocus>. <Skillful interventions> was extracted, because<Role complementation> This subcategory means that a
sub-facilitator, whose main role was to provide education,
and a facilitator, whose main role was to make interventions
so that group dynamics would start to work in the discussion, understood each other’s roles and complemented eachother’s weak points.
Participant 3: “I have always . . . thought positively, and I
controlled myself as much as I can so that I would not be
depressed. When recurrence occurred, I thought it was
the same as death. But, thanks to this place, I can now
expect my hair will grow again and expect other good48

Partnership in group intervention

facilitators had virtual experiences in facilitator training as facilitators and patients in group interventions. In
particular, experienced facilitators were considered to
be able to make some interventions based on their pastexperiences, because they had encountered various scenarios. On the other hand, not only new facilitators, butalso experienced facilitators experienced <defense of theposition of medical professionals> and <interventions
out of focus>, suggesting that it is very difficult even forexperienced facilitators to always make effective groupinterventions in a stream of group interventions. However, even if facilitators and sub-facilitators could not makeskillful interventions, their feelings that they wanted tointeract with and support the participants with all theirmight were conveyed to the participants as “hard effort”.
Probably for this reason, the participants supported
facilitators and continuously attended as many as 6 sessions. Concerning qualifications required for facilitators,
this study suggested that it is necessary for facilitators tohave an attitude of not being dependent on others only
because they are new facilitators, or are not satisfied
with their experiences, as well as an attitude of continuously and seriously facing participants, as described by
Spiegel et al.14 and Kiba et al.15 This indeed was considered to be the basic attitude required for facilitators who
handle group interventions.
The category of “harmony of the whole group” included 3 subcategories, <watching over movements>,<promotion of exchange> and <enhancement of mutual
support>. These intervention forms, observed in both
new and experienced facilitators, are required to construct and maintain group dynamics that improve theeffectiveness of group interventions. These results may
be attributable to facilitator training, as in the case ofbasic facilitator skills, and the fact that facilitators discussed the condition of each participant and movementsin each group before and after every group intervention
and thereby obtained suggestions for better intervention
methods. In addition, it was considered that <watchingover movements> alone made group dynamics work indiscussion, since the subjects were female patients which
and were given an explanation about discussion sessions
when recruited. There are female patients has resistanceto talk each other less than male patients.
<Role complementation> and <need for support>
were extracted in experienced and new facilitators, respectively, as subcategories of the category of “collaboration between therapists”. New facilitators have little
empirical knowledge and sometimes do not know how
to manage a group, which may influence the harmony of
the whole group, and eventually influence whether or notgroup dynamics work well. Classen et al.7 pointed outthat if facilitators have little experience, group interventions are often less effective. From this, if a new facilitator makes interventions, it is recommended to assign anexperienced facilitator as his/her partner or to deploy
additional staff so that other staff can oversee the whole
picture and support the new facilitator.
To improve the effectiveness of group interventions,
it is important that facilitators adjust the environment sothat group dynamics work, as described by Yalom and
Vinogradov.11 The results of this study showed that there
was a structure in which “harmony of the whole group”
and “collaboration between therapists” coexisted basedon the basic attitude of “hard effort”. In addition, these3 subcategories created partnership among facilitators,
sub-facilitators and participants. Yalom and Vinogradov11 reported that group interventions created groupdynamics in which participants understood each other’ssituation and supported each other. The present study
also showed that group dynamics worked in group interventions. A characteristic feature observed in the present
study was that even when facilitators and sub-facilitators
were beginners, group interventions allowed participants
to understand each other’s situation and support eachother. Classen7 stated that interventions by new facilitators could not contribute to the improvement of the quality of life of participants, but this does not seem to be thecase if the group dynamics of the participants.
In conlusion, A qualitative inductive analysis of theverbatim transcripts of group interventions extracted 3
categories, “hard effort,” “harmony of the whole group”
and “collaboration between therapists,” as [partnership]
which is a factor creating group dynamics. There was astructure in which “harmony of the whole group” and“collaboration between therapists” coexisted based on
the basic attitude of “hard effort.” It is suggested thatthese 3 intervention forms are involved in group dynamics in which participants can have smooth discussions,and that these forms are techniques necessary for groupinterventions contributing to changes in the quality oflife of the participants.
The authors declare no conflict of interest.
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