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.