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Click here to read Dowling's Dissertation Abstract

Dissertation to Study
Group Psychotherapy
with focus on Stigma
posted March 2003

by Vicki Dowling

My interest in my dissertation topic "A Coping Skills Short-Term Psychotherapy Group for Psoriasis Patients: Understanding and Coping with the Psychological and Physical Effects of Psoriasis" originates from personal struggle, and success, with my own battle with psoriasis.

I became afflicted with psoriasis at the age of ten with very few treatment options, and little understanding of the disease. Having reached a point of desperation and hopelessness in my late teens, I looked to the National Psoriasis Foundation for support, comfort, and understanding. Through educating myself about psoriasis and my own perseverance, I returned to school to finish my bachelor’s degree. Several years later, with the mentoring of a wonderful supervisor, and the support of family and friends, I finally found the courage to pursue my doctorate, hoping to make a contribution where I recognized there was a deficit.

I wish to work towards improving the quality of life of those with chronic illness, particularly those with psoriasis, partially by helping to educate those who are ignorant of the overall impact of the disease. Empathy and understanding are essential in helping people with psoriasis learn to help themselves. Education of medical providers, both physicians and psychologists, is necessary regarding the true nature of psoriasis, its impact on the lives of patients, and treatment difficulties. If I can make even a small contribution, I will feel rewarded on many levels.

I would be pleased to see others gain confidence that they may have once known, or may never have known before.

Attending a support group, not a psychotherapy group, sponsored by the National Psoriasis Foundation is what really turned me in a more positive direction. I hope that participating in a psychotherapy group will achieve positive results for others suffering from psoriasis. My hope is that through a group experience, members will begin to recognize the universality of their psoriasis, and feel more hope for improving their overall quality of life.

I am aware that my personal experience with psoriasis enhances the likelihood for my personal bias to be reflected in this study. However, I intend to utilize supervision to assist with potential issues and attempt to be even more cognizant of this since I acknowledge this issue. I believe also that my personal struggles with the disease give me greater empathy and understanding. Though I do intend to reveal that I have psoriasis to participating group members, my disclosure will be limited, keeping the consideration of group members’ needs primary.

Though emotions do not appear to cause psoriasis, they do seem to affect the etiology and severity of the disease. Because the ramifications of psoriasis vary widely both physically and emotionally from one individual to another, and from one episode or flare to another within the same individual, it can impact the lives of some patients quite significantly while affecting others minimally and/or very differently.

Researchers emphasize that "very little is known about how physical, psychological, social and environmental factors interact either to protect patients or place them at higher risk for negative impact."

Psychotherapeutically oriented group experiences have the potential to positively affect the way in which people with psoriasis make appraisals and respond to physical and emotional effects of psoriasis, other people, and their own lives in general. Through group interaction, people with psoriasis may become cognizant of how they relate to others, learn new coping skills, feel less alone, and may have suggestions that offer relief to others. Group participation facilitates learning and growth.

Historically, group therapy has its beginning in medicine, amongst patients with tuberculosis. Group psychotherapy for medically ill patients places emphasis on increasing quality of life, while recognizing both interpersonal and intrapersonal strengths of individual members. In addition to the anticipated cohesion of a more homogeneous group in general, my hope is that in the event that an individual member’s psoriasis flares, that group acceptance and understanding will further bond the group, normalize feelings of anxiety and depression, and provide concrete support to the member. Group psychotherapy may even be more effective for some than individual psychotherapy.

Though only three studies to date have examined the effects of group settings with individuals with psoriasis, many more studies have been done examining the effects of group psychotherapy with a wide variety of illnesses, including AIDS, arthritis, cancer, heart disease, irritable bowel syndrome, and multiple sclerosis amongst others, with positive and significant results.

Only one of the three studies with psoriasis patients was actually facilitated by a clinical psychologist. One was co-facilitated by a dermatologist and psoriatic patient who trained together, and the other was simply a support group for individuals participating in a day treatment center for people with psoriasis. Both facilitated groups combined educational and experiential components, and found positive results that were maintained at follow-ups of six months for one and two years for the other. Though each looked at slightly different variables, both facilitated groups supported the overall increase in quality of life. The support group emphasized the importance of social support in facilitating coping with the disease.

My interest in focusing primarily on stigma, social support, and coping and appraisal originates from the frequency of these issues being raised in both the academic and lay literature, as well as the topics of discussion in support groups such as the ones I attended in my earlier years, and the one I facilitated before returning to graduate school. Each of these predictors has the potential to affect anxiety and depression, or the worsening of psoriasis, and become part of a vicious cycle, as they are invariably interconnected. Each of these can affect treatment compliance, which in and of itself can become part of a cyclical downward spiral.

Though I will following Yalom’s group psychotherapy model and emphasizing his curative factors, my interest in exploring existential issues relates to the concerns that many suffering from psoriasis may have regarding meaning and quality of life, just as individuals with any chronic and/or terminal illness may have. Many of the curative factors from Yalom’s group psychotherapy model have the potential to impact feelings of stigma, social support and coping. Hope, universality, altruism, cohesion, interpersonal learning, and existential factors may be particularly useful in this time-limited approach.

It is anticipated that this study will contribute to a greater awareness of the inseparable mind-body connections of those suffering from psoriasis, and promote significant improvement in ability to cope with psoriasis and life in general through group psychotherapy, thereby improving overall quality of life.

It is further hoped that participants will gain enough confidence and self-esteem to better communicate their concerns and needs to family, friends, and medical practitioners, subsequently educating the general public and getting their needs met.

Most of the academic literature specifically related to psoriasis and its emotional effects comes from nursing and dermatology rather than psychology. This lack of psychological literature is one of the reasons I have chosen to contribute further to this particular field of study. Furthermore, through my professional experience leading a support group for people with psoriasis, I repeatedly observed the importance of having the support of group members in a safe arena to discuss feelings around coping with psoriasis.

Current empirical research of the psychological effects of psoriasis is limited, and mostly less clinical in nature. It is anticipated that participation in the proposed psychotherapy group will improve the overall mental, and in turn physical, health of its members, thereby supporting the necessity of more widely available and accepted psychotherapeutic treatment for such individuals. This recognition is important by those suffering from the illness as well as those capable of providing therapeutic services. It is also hoped that the results of the proposed study will encourage continued clinical research in the arena of group psychotherapy for those with psoriasis.

In closing, my interest lies in emphasizing the inseparable mind-body connections of those suffering from psoriasis, and providing a relatively safe environment and some tools to make more effective appraisals and better cope with this chronic, stigmatizing, and discouraging disease.  


ABSTRACT

This study examined qualitative responses from women with psoriasis participating in short-term, time-limited group psychotherapy, utilizing Irvin Yalom’s psychotherapy approach.  The group was both psychoeducational and process oriented, utilizing existential/interpersonal and cognitive-behavioral styles to facilitate coping, utilization of relaxation techniques, and interpersonal interaction.  This study examined some psychosocial consequences of psoriasis (anxiety, depression, self-esteem, and quality of life) in relation to some psychosocial predictors of adjustment to psoriasis, including stigmatization, social support, coping, and appraisal through a ten-week group experience.

This study provides a comprehensive qualitative analysis of participant responses and group changes as an exploratory approach for future experimental studies by assessing changes in both individual group members and the group as a whole from the beginning to the end of the study, focusing on the presence, absence and changes in Yalom’s therapeutic factors.  The data revealed that psychotherapy group participation was beneficial for all members.  Participants became more cognizant of how they related to others, learned new coping skills, and developed a better understanding of the importance of social support.  Most group members indicated one or more of the following benefits: decreased feelings of anxiety and depression; an increase in quality of life and feelings of self-esteem; and a greater ability to cope.

Previous research focused primarily on individual differences in feelings of anxiety, depression, self-esteem and coping rather than examining the powerful group process itself.  This study supports the findings of five previous studies regarding the benefits of social support and educational training to people with psoriasis, but additionally, acknowledges the significance of the group process itself.  Recommendations for future clinical and empirical research are made.

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