Sharing Skills and Picking Up Resources
An important aspect of SHARP-PWP for participants may have been the
focus on resources and resourcefulness. Many participants stated that
they valued the opportunity to learn about resources to address common
concerns in living with Parkinson’s disease. One participant appreciated
hearing about “what’s out there, the resources” while another
highlighted, “we got a list of resources and things that …
people around the table had found helpful and that other people could
utilize”. Participants reflected on how they learned skills and
approaches from group members to deal with difficult situations. One
participant commented on the opportunities to share coping strategies,
“…I’ve come across this particular situation or a situation like
this, this is how I’ve dealt with it”. Still others reflected on the
benefits of this learning, “I was not aware of what some of the things
people were doing and they were certainly not aware of some of the
things that I was doing”, Finally, some participants described the
value in learning about both preferred and less desired ways of coping.
One participant described “Seeing the differences between how people
handle it and learning from that - admiring the way some people have
coped and thinking ‘I wanna be like that’ or looking at some other
people and thinking ‘I don’t wanna be like that”’.
Self-Reflecting Leading to
Personal Insight
Some participants found the
facilitated self-reflection and resulting personal insights an important
part of the SHARP-PWP process. Encouraged to reflect on themselves as
unique individuals apart from their diagnosis, identity – particularly
as articulated in one’s hopes for the future – may have been an
important feature of the process. One participant explained, the group
“made you think what symbolizes hope for you, what do you look for. It
was useful”. Another group member described the process. “The next
week when we had to explain. It was like, ‘Oh why did I pick this
[hope] picture?’ … Then I realized that these are things that
I wanna keep on doing. So the hope is that those things are still gonna
be important in another 10 years or so”. The SHARP-PWP focus on
personal strengths may have been experienced similarly: “I thought that
was a good session personally in terms of trying to identify what my
strengths were. You don’t necessarily think about that every day”.
Discussion
Many people with PD face
progressively debilitating motor symptoms alongside PD-related apathy,
depression and anxiety (Gallagher & Schrag, 2012). For those with PD,
the tendency to view one’s symptoms through a pessimistic lens has been
shown to have a detrimental impact on quality of life and mental health
outcomes (Lerman et al., 2019). Group interventions focused explicitly
upon the therapeutic process of hope have the potential to help
individuals build skills and attitudes to enhance quality of life
(Murdoch et al., 2020). This study focused on group experiences that
participants described as important and helpful to them. Participants in
this study discussed seven helpful factors within the group: (1)
Accessing Hope, (2) Discovering Commonality, (3) Drawing Together, (4)
Reaching Out Beyond Self, (5) Releasing Emotion, (6) Sharing Skills and
Picking Up Resources, and (7) Self-Reflecting Leads to Personal Insight.
Group facilitation is also discussed.
Accessing Hope
Finding ways to access hope in
the face of Parkinson’s Disease was identified by group members as an
important facet of the group experience. Participants’ descriptions ofaccessing hope during the SHARP-PWP treatment seem to align with
a nuanced or mature hope, often deeply existential at its core.
Hope—or an awareness of the need for hope—often arises in the
context of suffering and uncertainty (Frankl, 1985; Marcel, 1962; Nwoye,
2011). A mature hope includes developing the ability and courage to
envision and activate desirable futures while in full realization of the
vicissitudes of life (Larsen, Hudson Breen, Murdoch, & Hobbs, under
review). In this study, hope was elicited from clients and cultivated
via intentional practices on the part of therapists, thereby
facilitating a growing awareness of hope amongst group members even in
the face of difficulty.
Psychological group interventions
with an explicit and intentional hope focus are uncommon and rarer still
in the support of individuals with PD. Further, most psychological
interventions for PD tend to be problem-focused in as much as their
explicit goal is to alleviate specific struggles (e.g., stress, pain,
depression, anxiety; Gelso & Woodhouse, 2003; Lopes et al., 2021).
Nonetheless, activation of resources is a therapeutic change mechanism
with strong research support (e.g., Fluckinger & Holtforth, 2008;
Fluckinger et al., 2013) and realized in interventions that focus not on
the patient’s problems but rather on the many sound and healthy parts of
the individual’s personality (Gassmann & Grawe, 2006; Munoz et al.,
2020).With its focus on client hope and client strengths, SHARP-PWP may
offer a window into a hope and resource-intensive approach to group
intervention. Specifically, the presenting problem, while acknowledged,
is explicitly not the focus of treatment. Instead, clients are
encouraged to reflect on their already-existing personal experiences of
hope and stories of strengths. To respectfully guide a SHARP-PWP group
requires an effective therapeutic plan (Edey et al., under review) and
leaders committed to creating a safe container and sustaining a hope and
strengths focus on the group work.
Drawing Together,
Comparing, and Reaching Out Beyond Self
Relationships among group members
were identified by participants as fundamentally helpful. Themes of
Reaching Out Beyond Self, Discovering Commonality, and Drawing Together
highlight the importance of relationships within the SHARP-PWP group.
Group members described their bonds with one another as crucial to the
therapeutic experience and, while based in part on a shared sense of
common enemy, these bonds may also include an existential relief at no
longer feeling alone in their experience of Parkinson’s. It is as Nwoye
(2011) reminds,
Often, what is essential …
is for the hoper to gain either some direct or vicarious contact with
another human being who has suffered a similar tragedy to the one the
helper is now facing but who has been able to escape the captivity
presented, through time, patience, and forbearance (p. 12).
Some participants also describe
profound learning found in witnessing one another’s’ strengths as well
as their own. Qualitative findings from a previous iteration of the
SHARP program, the Being Hopeful In the Face of Chronic Pain (BHIFCP)
group, examined group member experiences via two specific interventions:
hope collage (Larsen et al., 2015) and strengths cards (Larsen et al,
2018), exercises common to both BHIFCP and SHARP-PWP. Like the current
study, participants in BHIFCP groups identified group relationships as
an important element in treatment and included themes such as communion,
universality/connection, and coming together in hope. Research on
therapeutic factors demonstrates that group cohesion (Dierick &
Lietaer, 2008), relational impact, and social learning (Joyce et al.,
2011) are correlated positively with group outcome. Further,
relationships are consistently identified as a key source of hope across
the now large body of hope research (e.g., Larsen, et al., under
review), while research on individual therapy demonstrates that clients’
hope is connected to a sense of safety and acceptance found specifically
in the therapeutic relationship (Bartholomew et al., 2021; Larsen &
Stege, 2010a).
Emotional Release
Another important aspect of
SHARP-PWP identified by participants was the opportunity to safelyrelease emotions they experienced as a result of living with
Parkinson’s. Secure emotional expression is a therapeutic factor
commonly associated with group member outcome (Joyce et al., 2011;
MacNair-Semands et al., 2010). In fact, quantitative analysis in the
SHARP-PWP group confirmed that secure emotional expression in the group
was predictive of increases in well-being (Murdoch et al., 2020).
Further, this project highlights potential new information regarding the
relationship between hope and emotional release in a therapeutic
context. The experience of hope – or the need for hope – may rise to
awareness in the face of suffering and uncertainty (Frankl, 1985;
Marcel, 1962), contexts prone to fostering difficult emotions. Hope can
often involve developing the ability and the courage to envision
possible desirable futures while also experiencing the vicissitudes of
life (Larsen et al., under review). In a study of hope and individual
therapy, clients identified time spent describing the problem as their
sole experience of hopelessness (Larsen & Stege, 2012) while
acknowledging the importance of the therapeutic relationship as a source
of hope, typified by feelings of safety/acceptance, being heard and
understood, and genuine therapist investment in the face of difficulty.
Indeed, experiencing safety/acceptance, being heard, while also
recognizing the investment of one’s therapist may be a critical
counterbalance to client experiences of hopelessness and vulnerability
(Egeli et al, 2014) as they address difficult emotions.
Within group treatment, a
relatively homogeneous group such as SHARP-PWP may be ideally
constituted to serve important hope fostering functions including the
creation of safety in emotional release, the sense that one is genuinely
heard and understood, and the feeling that group peers are authentically
invested. This may be especially so given that group members share
common recent contexts and experiences. Thus, while safety, emotional
release and feelings of safety/acknowledgement may be common to many
support groups, this research appears to be amongst a handful of
instances in which scholars directly point to relationships between
experiences of hopelessness, emotional release, group support, and
finding hope within group therapy (e.g., Larsen, et al., 2015; Larsen et
al., 2018; O’Hara, 2013). One of the features that may set the SHARP-PWP
approach apart from other support groups is the manner and skill with
which the group fosters and supports emotional release while also very
intentionally tilting the group process toward the development of hope
experiences and hope skills. In short, group member hope may be found in
emotional release and in facilitator skills that both offer hope found
in safety/acceptance and moving beyond the problem to accessing hope
found in life more broadly as well.
Sharing Skills
Sharing skills and resources was identified by research participants as
an important experience within the group. Sharing skills suggest the
importance of peer modeling and teaching in the SHARP-PWP. Modeling is a
well-established learning process (Bandura, 1971) akin to Yalom’s (1995)
therapeutic factor of “imitative behaviors.” Further, modeling has
been increasingly recognized as a social process associated with
positive treatment response (Faase & Petrie, 2016). According to the
SHARP-PWP program plan, SHARP-PWP is “predicated on the conviction that
members are interesting, capable, and multifaceted people” (Edey et
al., under review). Facilitators should ideally trust in the
resourcefulness, uniqueness, and strengths of group members to model
strengths, hope, and resourceful behaviors for peers, highlighting that
valuable personal client assets are available even in the face of
Parkinson’s. Where it was once thought that, “[t]he best model is
often the therapist” (Borgers, 1983), SHARP-PWP is attentive to and
lifts up the skills and resources brought by participants rather than
viewing the facilitator as the primary role model, underscoring the
wisdom of clients. While the SHARP-PWP facilitator plays an important
role in setting a group tone focused on strengths, hope, and resources
in this unique supportive therapy, the therapeutic model relies on
clients experiencing, sharing, and modeling personal strengths.
SHARP-PWP’s reliance on group member strengths extends to practical
resources, such as information sheets and self-help resources.
Participants describe the benefits of creating a list of useful
resources for people with Parkinson’s, highlighting that this, too, was
facilitated as a group task. Self-help resources have long been shown to
have beneficial therapeutic effects in the treatment of anxiety,
depression and other mental health issues (Fischer et al., 2020; Haug et
al., 2012). The hope fostering effect of gaining resources when faced
with a serious health condition has been highlighted in other health
studies as associated with empowerment and hope for the future (Harris
& Larsen, 2007). Tasking group members with creating their own resource
list is different from many professionally led health support groups
wherein participants are commonly the recipients of expertresources delivered as part of the program. In SHARP-PWP, the reliance
on client-generated practical resources is, again, suggestive of a
strengths-based therapeutic model rather than a pathologizing
orientation to group work. Within SHARP-PWP, group members were
seemingly recognized as experts on their experience and most
well-equipped to identify and to share the resources they found helpful.
According to the group program plan (Edey, et al, under review) an
additional unique feature of SHARP-PWP is its trans-group resource list,
wherein resource lists created by past SHARP-PWP groups are shared with
current groups. New resources are added by the current group members
with the intention of passing the new list on to future SHARP-PWP group
members.
Self-reflecting
Participants describe
self-reflection focused on their personal resources and hoped-for
futures as an important part of the SHARP-PWP process, leading to valued
personal insights. Self-insight is a therapeutic factor shown to be
positively correlated with group member outcome (Dierick & Lietaer,
2008) attained through self-reflection. Self-reflection/personal insight
has long been held as a potentially important facet of group therapies
(Kealy et al., 2017). However, perhaps not all self-reflection is
created equal. For individuals facing difficulties and uncertain
futures, pessimism, stress, and fear are common and the prospect of
future good can become threatened, engendering hopelessness. Depression
and anxiety may often include self-critical symptomatology (Werner, et
al., 2019). By taking a strengths-based view of clients, SHARP-PWP
facilitators encourage positive self-reflection even as group members
face PD. As such, SHARP-PWP participants underscored the satisfying
benefits gained via self-reflection specifically when directed toward a
deepened personal awareness and understanding of their own hope,
strengths, and abilities. Similarly, in a study of hope-focused
individual therapy, clients identified therapeutic interventions that
supported positive identity development as fostering hope (Larsen &
Stege, 2012). In the face of difficulty, one’s awareness of important
personal resources has the potential to be lost to fear. Personal
resource activation is a change mechanism with promising research
evidence (Gassman & Grawe, 2004). As shown by these findings, a
directed self-reflective focus on enhanced insight into one’s strengths,
hope, and personal resources may serve as an important means of
activating valuable resources when living with PD.
Facilitating SHARP-PWP
The skillful delivery of
SHARP-PWP may involve a paradigmatic turn from the common expectation of
a health support group wherein cohesion is fostered through discussions
of shared suffering and loss. Preserving sensitivity and skill with
addressing client pain while helping group members move on to access the
breadth of life beyond Parkinson’s may constitute the challenging task
of the SHARP-PWP facilitator. Clinicians taking on this work are
encouraged to be intentional and committed to exploring, learning, and
experimenting with hope fostering clinical skills (Larsen et al., under
review).
Facilitators’ approach to delivery
of SHARP-PWP seems critical, requiring both therapeutic commitment and
skill in facilitating a distinctly hope and strengths focused
intervention. This may be particularly true in the context of a
disciplinary history and culture commonly permeated with an implicit
conviction for entity beliefs (i.e., fixed mindset) about psychological
health and a corresponding determination to seek health by building an
increasingly sophisticated understanding of psychopathology (Howell,
2017). An explicit focus on hope and strengths instead encourages a
sophisticated understanding of client abilities and resources -
fostering an incremental (i.e., growth-oriented) mindset. Howell (2017)
asserts that an incremental mindset is an important precursor to client
change in psychotherapy. Gelso and Fassinger (1990) assert that the
study of client’s strengths and assets represents an area of counseling
psychology’s unfulfilled promise. While the field of psychology has
begun to move in the direction of synthesizing positive and negative
experiences, there are still far too few field-based research studies
examining positive, strengths focused clinical innovations (Harbin et
al., 2014).
Limitations and Future
Research
As a qualitative study employing
a relatively small sample size, this study was designed to offer
information on positively oriented group counselling practices for
people with PD. Findings are promising, however, future research with
SHARP-PWP should employ mixed methods including randomized control
trials to establish quantitative evidence of program effectiveness while
also engaging qualitative methods (such as interpersonal process recall)
designed to explore micro processes taking place during treatment. In
doing so, researchers and clinicians will better understand the potency
of positively oriented interventions, the change mechanisms involved,
and meaningful nuances important for clinical practice.
Summary
Participants in SHARP-PWP reported
that they found the group helpful, wanted it to last longer, and
articulated several helpful processes. Findings suggest that a hope,
strengths and resourcefulness group treatment may offer a promise for
those within five years of a PD diagnosis. Seven processes were
identified by group members as helpful: Accessing Hope, Comparing,
Drawing Together, Reaching Beyond Self, Releasing Emotion, Sharing
Skills/Picking Up Resources, Self-Reflecting/Personal Insight. Attending
to group facilitator skills specific to a positively-oriented hope,
strengths, and resourcefulness group appears to be an important facet of
program delivery.