A qualitative exploration of the lived experiences and perceived impact of a supportive-expressive group therapy on men living with gastrointestinal cancer : Journal of Psychosocial Oncology Research and Practice

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Original Article

A qualitative exploration of the lived experiences and perceived impact of a supportive-expressive group therapy on men living with gastrointestinal cancer

Martopullo, Celestinaa,b; Oberoi, Devesh V.a,b; Carlson, Linda E.a,b; Bultz, Barry D.a,b,*

Author Information
Journal of Psychosocial Oncology Research and Practice 5(1):, January-March 2023. | DOI: 10.1097/OR9.0000000000000091

Abstract

1. Introduction

Despite significant biomedical advances in cancer control and management, the cancer experience continues to be marked by a high prevalence of mood and adjustment disorders, psychiatric morbidity, and existential distress.[1–3] Such experiences, across the cancer continuum, expose patients to a range of physical and psychosocial morbidities resulting in diminished quality of life, strain on interpersonal relationships, and major challenges in coping and adjustment.[4,5] The need for psychosocial interventions to mitigate biopsychosocial-spiritual-existential distress and improve patients' overall quality of life has been well-recognized. Many psycho-oncology programs deliver theoretically sound and empirically based interventions to address the emotional burden of the disease and improve patients' mental health, psychosocial functioning, coping, adjustment, and overall quality of life.[6,7] One such intervention is supportive-expressive group therapy (SEGT)[8]—with numerous randomized controlled clinical trials (RCTs) supporting its efficacy in improving emotional health outcomes through processes of validation, acceptance, expressive disclosure, and emotional exploration.[9–11] Historically, SEGT was designed and delivered to enhance coping and adjustment in patients with advanced breast cancer,[8,9] and its adaptation across other cancers, mostly ovarian, is documented in several reports.[12] However, SEGT's generalizability across a range of sexes remains unexplored.[13] In this study, we focus specifically on the sex of men. Not much is known about men's existential-emotional support needs across cancers, and studies on relevant interventions are scarce in the literature. Reports on men's health claim that male patients with cancer, who largely identify as men, prefer informational exchanges as opposed to emotional expression or solicitation in group formats.[14] Most interventions offered to men, particularly to patients with prostate or testicular cancer, are predominantly psychoeducational or informational in nature with little to no emphasis on exploring their emotional needs.[15]

In a context of limited information about sex differences on attending emotionally focused group interventions across cancers, we previously conducted 2 studies with male patients with gastrointestinal (GI) cancer attending an existing, professionally led, men-only group therapy with a supportive-expressive focus.[13,16] The first qualitative study explored men's motivation for joining the group, pointing to “affiliating with similar others” and “learning about coping” as the main reasons[16]; the second study, a longitudinal quantitative evaluation of group effectiveness, revealed that SEGT was effective in reducing illness-related anxiety, depression, and anger and improving coping strategies among male patients with GI cancer.[13] However, the quantitative evaluation did not capture how the men's lived experiences with the SEGT dynamics enhanced psychosocial outcomes. The social and relational dimensions of this group as a unique, sex-sensitive, and experiential phenomenon needed to be further understood and interpreted. Therefore, this study sought to (1) learn about the lived experiences of men diagnosed with patients with GI cancer attending the SEGT over time and (2) explore the perceived benefits of the intervention in relation to the goals of supportive-expressive therapy. Through this study, we hoped to generate much needed insight that could inform the design and substantiate the delivery of professionally led groups that are well-equipped to offer emotional, existential, coping, and informational support to men living with GI cancer.

2. Methods

2.1. Participants and setting

A convenience sample of participants was recruited from an ongoing professionally led SEGT program for male patients with GI cancer in the Department of Psychosocial Oncology (Tom Baker Cancer Centre, TBCC) in Calgary, Alberta, Canada. Men were referred to the group by the GI psychosocial and health care teams, self-referral, marketing brochures, and word of mouth from other patients attending the group.

While the group was advertised as a “men's” group, people of biological sex other than male would have been welcome to join if they identified as “men.” This, however, never arose, so all the participants were also male sex. The TBCC is a large tertiary cancer center that serves the population of Southern Alberta. Men who were older than 18 years diagnosed with any type of GI cancer, able to communicate in English, and attending the ongoing SEGT at the TBCC for at least 3 months were eligible to participate in this study. There were no restrictions relevant to the stage of the disease, treatment phase, or time since diagnosis. The exclusion criteria related to any cognitive impairment precluding group participation. Men eligible to join the group were invited by two research assistants to participate in this study. Eligible participants were interviewed by the research assistants. Study participation was voluntary and independent of group enrollment, attendance, or entitlement to other psychosocial services in the department. The research team conducted brief intake interview to determine eligibility for group: (1) what are men's emotional, social, existential unmet needs; (2) described the content, process, format, and clinical outcomes of the SEGT; and (3) described the purpose of this study (group enrollment is not conditioned on the study participation). Yet, many men who were eligible for the group also chose not to participate or attend sessions, and therefore, more research is required to also understand why men decline group therapy and if there are differences in characteristics between attendees and nonattendees.

2.2. Ethics

This study was approved by the Research Ethics Board of Alberta—Cancer Care (HREBA-CC) at the University of Calgary.

2.3. Procedure

2.3.1. Intervention

SEGT is a semistructured intervention based on existential psychotherapy.[17] It was initially developed by Spiegel et al and emphasizes the need to recognize and work on existential concerns related to fear of death, isolation, meaning, and life purpose for women with metastatic breast cancer.[10] In addition, SEGT addresses emotional, interpersonal, and practical challenges faced by patients with cancer.[18] The primary goals of SEGT are to facilitate mutual support among group members, promote emotional expressiveness both within and outside the group, promote the integration of a changed self and body image into the patient's current view of the self, and improve coping skills. The intervention also focuses on improving social and family support, improving doctor-patient relationships, detoxifying feelings around death and dying, promoting reordering of life priorities, and enhancing the current quality of life. The main principles guiding treatment decisions in sessions are maintaining the focus on cancer, promoting the expression and exploration of feelings and thoughts, facilitating supportive interaction among group members, focusing on personal and concrete issues, and facilitating active coping.[17]

Our intervention was a 90-minute biweekly, professionally led, semistructured, on-going cancer support group therapy guided by the principles and goals of the SEGT and delivered through a drop-in format. This format allowed for flexibility in attendance (often influenced by medical reasons) and assured consistent availability of the group intervention. Group facilitation was offered in dyads by three psycho-oncologists (one woman and two men) at the TBCC.

2.4. Data collection

Participants were informed about the objectives of this study. Interested participants provided written informed consent to participate and be audiotaped. Participation was voluntary, and no monetary compensation or any kind of incentive was offered. Interviews occurred at the TBCC and were conducted by research assistants with experience in conducting interviews.

Participants were interviewed at two time intervals—3 months (Time 1) and 6 months (Time 2)—from the time of enrollment in the group. They were asked about their lived experiences with the support group and any perceived benefits in relation to the SEGT goals using open-ended semistructured interviews. Interviews were conducted face-to-face to explore men's lived experiences with group over time, likes, dislikes, compliance with expectations, and continuance with group attendance. Targeted questions informed by the SET goals were asked to explore the perceived benefits of group participation over time (Appendix 1, https://links.lww.com/OR9/A39). Interviews lasted between 60 and 90 minutes. Interview questions were informed by literature, clinical experience, and supportive-expressive therapy goals. With participants' permission, the interviews were audiotaped and transcribed verbatim for analysis. Field notes were taken during the interviews. Data were deidentified before the analysis.

2.5. Data analysis

The interview data were analyzed using an integrated (hybrid) Approach—incorporating inductive and framework analysis[19] in keeping with a realist-essentialist paradigm.[20] The inductive thematic analysis allowed for an exploratory approach to understand the lived experiences of men's group participation and experience over time. The framework analysis, grounded on the preliminary data scanning and questions informed by SEGT, provided systemic and visible stages of text segmentation, allowing for iterative analysis and interpretation of emerging data. The first-level coding involved data set immersion, initial code generation, and the development of a flexible code structure for grouping units into categories. The second-level analysis involved immersion with the preliminary coded data, sorting “semantic” and “latent” themes representing a patterned response. Themes were reviewed back and forth with the original data set to ensure fit and intercoder agreement. The final themes generated consensus from the study team members and were supported by the data. Rigour was supported by full data immersion, iteration, consensus coding, peer debriefing, reflexive analysis, and an audit trail.[21] The themes were supplemented by direct quotes from the participants whenever possible and used to support the themes. QSR NVivo 12 software facilitated data management and analysis. Participants' sociodemographic characteristics were analyzed and reported using the statistical platform SPSS v. 25. The data extraction and the content analysis were conducted primarily and independently by the first and the second authors. Final codes and themes were discussed with authors until a consensus was reached.

3. Results

3.1. Participants

We interviewed twenty-three men at 3 months into group participation and thirteen of these same men at 6 months. The participants' mean age at the time of enrollment in the study was 55.96 (±11.64) years. Most participants were diagnosed with advanced stage (state 3 or 4) cancer. At 6 months (T2), n = 11 dropped out for the following reasons: deceased (n = 5), moved out of province (n = 3), deteriorating health (n = 2), and returned to work (n = 1). The maximum number of group sessions attended by the participants over the study period was 13, and the mean number attended was 5.56 (standard deviation ±3.68) sessions. Participant sociodemographic characteristics are presented in Table 1.

Table 1 - Characteristics of participants who completed the assessments at 3 and 6 months from participation.
Variable 3 months (N = 23), n (%) 6 months (N = 13), n (%)
Age (mean ±SD) 55.96 (±11.64)
 18–30 1 (4.3) 1 (7.7)
 31–45 5 (21.7) 1 (15.4)
 46–60 8 (34.7) 6 (46.1)
 61–75 8 (34.7) 6 (46.1)
Highest level of education
 High school 3 (13.0) 2 (15.3)
 College/university 19 (82.6) 11 (84.6)
Ethnicity
 White 21 (91.3) 13 (100.0)
 African 1 (4.3)
 Asian 1 (4.3)
Marital status
 Married/common law 17 (73.9) 12 (92.3)
 Single/divorced/widowed 5 (21.7) 1 (7.7)
Employment status
 Employed (fulltime/part-time) 6 (26.0) 4 (30.7)
 Unemployed 15 (65.2) 9 (69.2)
Tumor type
 Colorectal 14 (60.9) 11 (84.6)
 Esophageal 1 (4.3) 1 (7.69)
 Stomach 1 (4.3) 1 (7.69)
 Pancreatic 3 (13.0)
 Liver 1 (4.3)
 Bile duct 1 (4.3)
Tumour stage
 1–2 5 (21.7) 4 (30.7)
 3–4 15 (65.21) 9 (69.2)
Time since diagnosis
 ≤6 months 8 (34.7) 5 (38.4)
 6.1–18 months 9 (39.1) 5 (38.4)
 >18.1 6 (26.0) 3 (23.0)

3.2. Themes

Findings were grouped into two main categories as per the objectives of this study: (1) group experiences over time and (2) perceived benefits in relation to the SEGT goals (Figure 1).

F1
Figure 1.:
Thematic analysis of the experiences of men in cancer support group.

3.2.1. Group experience over time

Despite variety in illness pathways, distress levels, coping mechanisms, or changes in health status, participants' accounts about group experience, at the 3-month and 6-month intervals, pointed to an overall global group satisfaction. At the 3-month interval, all participants revealed that group expectations were met or exceeded. As 1 participant put it, “I'm pleasantly surprised how good it's going… and how comfortable I feel, and how much I have to look forward to” (Participant 8). At both 3-month and 6-month intervals, men unanimously expressed interest to continue attending the group until, as 1 man put it, “They kick me out” (Participant 1). Even when getting a “clean health card” or feeling “guilty” for doing better, participants stated their preference to continue group attendance for altruistic motives to “give back” (support others) or maintain awareness of “what could be ahead.” Interestingly, no mention of any sort of adversaries or unproductive group aspects was shared.

With reference to group experience over time, three central themes were identified: (1) functioning of upward and downward social comparison mechanisms, (2) functioning of supportive-expressive exchanges, and (3) functioning of the group format.

3.2.1.1. Role of social comparison

Social comparison mechanisms facilitated positive changes in perspective, mood, and personal growth across our sample. The theme of engaging in upward comparison (with those faring better) and downward comparison (with those faring worse) in the group was quite prevalent at both time intervals. Interestingly, both upward and down comparison mechanisms contributed to positive group experiences.

There's a lot of different perspectives, and you can appreciate even if you are at a different stage …there's always someone doing better than you, someone doing worse than you, and I don't know you can feel better for both of those” (Participant 2).

The upward comparison was viewed as inspiring hope, awareness, and a positive perspective. Here is how 1 man puts it:

Well, it has changed me. It has made me think more clearly about my condition…and like I say, it keeps me grounded in the two sides of the equation that can happen. I'm hoping that…..umm… I'm moving towards the good side, but I don't take it for granted that things could change tomorrow” (Participant 4). (THEME: Upward social comparison)

The downward comparison contributed to mood improvement for many participants who found themselves “feeling fortunate” about their own situation, grounded, empathetic, and motivated to learn from those coping with worse situations. For example, 1 participant acknowledged “feeling for the gentlemen that you know that are in situations that are worse than mine. Umm, and you know it just makes me feel better about the situation that I am in.” (Participant 3).

Interestingly, 1 participant saw the downward comparison as “enlightening” and a way to minimize self-pitying:

I listen to some of the other guys that are dealing with things that are much more severe, and I guess, maybe even life-threatening…I say gee, I'm kind of lucky to this point in time, but then again by going, it gives you a lot of things to think about, and you see a lot and hear a lot of different perspectives, and I find that enlightening. Yeah, I've had this cancer, but I'm a lot better off right now than a lot of people, so let's not go feel sorry for yourself. The group helps” (Participant 1).

Whereas another man felt inspired to cope with potential health challenges:

…to have the positive attitude that he [fellow] does towards a really negative outcome… it is extraordinary… and said…I hope that if I’m ever in your scenario, I can deal with it the same way that you are… it’s quite a powerful group for some of the fellows that were scared, the young folks especially” (Participant 26).

Overall, social comparison mechanisms consistently facilitated positive changes in perspective, mood, and personal growth across our sample over time.

3.2.1.2. Role of supportive-expressive exchanges

At both 3-month and 6-month intervals, the group was continuously experienced as a unique, safe, reliable, and relatable medium for sharing feelings and emotional expression. Furthermore, participants described the group as a normalizing, validating, understanding, and mutually supportive alliance with similar peers.

Most participants spoke positively about the immediate effect of group sessions, commenting on how they “feel lighter” or “relieved” at the end of each session. One participant viewed group as “a great outlet. I always take something out of it, every session. Just to be able to talk about what you are going through, all that type of things, that's a release. My wife says I'm always positive when I come back from group” (Participant 2).

The group's inherent value had different functions for different participants, for example, "give back" for the ones in remission, “learn what could be ahead” for the ones in no acute distress, and alleviate anxiety and improve mood for the ones in distress. As 1 man puts it:

The group is definitely helpful in a lot of things, and everyone is different, and everyone's need is different, so here we take what we can from the group, little as it may be for some, I'm sure to others there is a lot they take out of it every meeting” Participant 12.

Another participant referred to the group as a “unique outlet” as “it gives you a few little ideas, things you can do and what to expect, you know there have been a few laughs and things like that” (Participant 11).

Men's accounts consistently pointed to supportive-expressive exchanges as fostering: mood improvement, positive outlook, personal growth, and cohesion. This is well encapsulated in 1 participant's words:

“Men tend not to express feelings in the greatest of ways, but I find that with time, and or people get to know each other in the group, that sort of relaxes a little bit… you start to be more relaxed about saying what is really going on with you and how you feel, and how are you feeling about your treatment and… ways things are going on and your emotional stuff and that kind of stuff…having a sounding board, if you know if you are having issues… you have a forum to kind of go and discuss it, figure out a strategy, figure out to how maybe best cope with something. The biggest thing is knowing you are not alone” (Participant 4).

Overall, supportive-expressive exchanges were shown to be relatable and beneficial to men living with cancer and at different stages of illness. These exchanges were appealing to all participants regardless of their distress levels or availability of natural support systems. It is this functioning appeal that kept participation going.

3.2.1.3. Role of group format, composition, and facilitation

All participants appreciated the GI-specific group composition as a medium of normalizing and validating similarities in treatment side effects and exchanging experiences in coping with them. Variety in illness trajectory described by 1 participant as: “sharing the same experiences at different degrees….” (Participant 2) and was experienced as fostering learning gains, personal growth, and self-efficacy:

Yeah, it has been pretty good, and it is a bunch of different… I guess guys at different stages in there, so it's good for different views… and perspectives(Participant 19). Another participant viewed variety in illness stages as beneficial in that “the guys that are in the remission are the guys that give you hope…the guys that are in distress are keeping you grounded in that you need to be prepared for the downside” (Participant 4).

The sex-specific group composition was mostly valued for making it “easy,” “more comfortable,” “relaxing,” and “open” to talk about sensitive topics such as bowel movements, intimacy, and sexuality. Interestingly, men felt comfortable in the presence of the female group facilitator, jokingly referring to her as “one of the guys.”

Most men appreciated the facilitators' inclusive and engaging style; their “no agenda” or a semistructured approach made participants feel, as 1 man put it like the “group is ours.” This is how 1 man describes his experience with group facilitation:

everybody gets a chance to speak, it's well shared, it's well managed, and I think it's living up to its purpose… put everybody at ease, I guess” (Participant 2).

Four men took up a position of critique toward the facilitators. One participant, while commenting on a fellow group member sharing a tense encounter with his oncologist, pointed out how “facilitators should have intervened faster rather than let the negativity affect the group” (Participant 29). Another man noted how sometimes “{facilitator} was trying to dig something that maybe is not there” (Participant 27). Another participant commented on how “when men in the group want to talk about the healthcare system, facilitators shouldn't necessarily put their opinions in” (Participant 4). Another one felt that {facilitator} changed the toping quickly when sexuality and cancer was being discussed.

Furthermore, all participants appreciated the drop-in nature, particularly the “no expiry date” of group sessions—viewing them as stress buffers. Most men enjoyed the group running every 2 weeks, except for two men who stated a preference for weekly sessions. Participants found the 90-minute session length quite adequate. Some men reported feeling comfortable having the same room designated to the meeting, with “a pot of coffee and name tags” waiting for them.

3.2.2. Perceived group benefits over time

The perceived benefits of group over time reflected outcomes that mattered to each participant and were in line with the SEGT goals. Most men consistently pointed to feeling heard and validated, feeling safe to express emotions and address fears or anxiety about death and dying, and also feeling empowered to re-evaluate life goals.

For many participants, the perceived benefit of being heard and validated accelerated a sense of belonging, acceptance, and significance—as 1 participant put it:It's nice to be part of a group where you're accepted and your experience is valuable… you give your experiences importance, I guess maybe to this group” (Participant 15).

Most men consistently shared how feeling heard and validated made it safe for them to express emotions:

For a group, probably one of the safest environments I have ever been exposed to, that would freely allow people to express their emotions and again, that is from facilitation if the comfort level has been established. It’s OK, and we have seen a lot of guys cry. We are sort of going like we are saying this is OK, we believe it is OK, but until it actually happens, we all get choked- up, you know, and it is at a point where you even cry too along with this person… it is more of an empathy element that is going on. Still, the guys feel permitted enough, and they have also given themselves permission.” (Participant 26).

Interestingly, for many participants, a normalizing group experience facilitated self-disclosure and acceptance of emotional reactions, which stereotypically are seen as signs of weakness. Here is how 1 participant put it:

…it’s interesting, you see other people sharing or baring their souls there, and you only realize that, and you you’re like WOW… and you know it’s easy… [because] you are respected and supported… you know like pretty much everybody I think, you know they are not holding back, just saying how they feel… There has been some sessions, some meeting that have been very emotional where probably everybody kind of having a really bad day and feeling that, and it has been a really good bonding moment a lot of times as well” (Participant 15).

The last session I talked about how I have problems, well not really problems, but I’m way more apt to crying now than I ever was before in my life…but it’s good, I’ve learned to accept that it is not a weakness to cry. I’ve realized that it is a release, and it is almost freeing” (Participant 2).

Other men reported how a supportive group climate enabled bonding and full emotional expression. The third, most consistent, largely shared perceived benefit of group participation pertains to the group serving as a therapeutic environment for exploring fears and anxiety regarding death and dying. Although many participants recognized the emotional difficulties, sometimes reluctance to approach topics of death or dying, for the most part, they acknowledged emotional, practical, and existential significance of sharing such themes in a supportive group environment. As 1 participant mentioned:

Talking about funeral arrangements is an emotional one, and it’s one that you really don’t want to talk about… some guys are getting close to the end… you get to know them, and then, all of a sudden, there’s a shock… the chair is empty… this puts perspective on what you are doing and on that this is a serious thing you are dealing with… we are supportive of each other, we sort of work through it… every once in a while we reminisce about that, we have discussions on potential outcomes…” (Participant 4).

For all participants, the passing of a group member induced sadness. As 1 man puts it:

…there is also a sad side to the group where you know unfortunately we had a member passed away recently. You know there is also a reminder as well of what you are going through and also in other way makes you very thankful for the fact that what I went through could have been a lot worse…” (Participant 11).

For most, sadness was reported to have triggered awareness, self-reflection, and a change in perspective relevant to their immediate medical situation. One man, whose health was deteriorating, found it helpful to share in group about the practicalities surrounding death and dying as he said:

Even on my downside I have been able to help the group for things that they and I said…you know you have to look at things where you have to look so you have proper protection for your wife when you die because your credit card could be only in your name…sharing with the group helped…I was very pleased about that” (Participant 5).

Interestingly, even when participants reported not fearing death per se, they appreciated sharing information about practicalities around death and dying. Engaging in self-awareness and reflection in a supportive group context contributed to many participants re-evaluate life values/goals, which was commonly linked to mood improvement:

You know, one of the guys at the group says you got to live each day as it is the best day, and that is a good goal. That is a goal I didn’t have on my plate before, but it is one of the guys brought up, and it is a good goal… whether you have terminal cancer or not, you come out of there with this different state of mind, absolutely… and the is always the uplift in your situation” (Participant 5).

Other SEGT goals, such as dealing with body changes, and improving communication with family and the medical team, reflected outcomes that carried different weight for each group participant. For example, issues around body changes were cited as nonconcerning for some participants and quite distressing for others who found it beneficial to explore them in a supportive group context. As 1 participant put it:

Risk of impotence, incontinence, sterility, just how you’re going to function… neuropathy…I don’t know… it helps with the fear with it… yeah just to cope with things as they go…” (Participant 29).

Similarly, with reference to the group helping with improving communication with family or the medical team, some participants noted that such had not been an issue for them. Others, who recognized improvements in communication, pointed to group experience supporting and enhancing “self-advocacy”:

some people get frustrated with the health care team… and other people would suggest things you know that help them to cope with it or what they do to advocate for themselves, and I guess that can kind of help the group” (Participant 12).

4. Discussion

The findings highlighted factors which promoted attendance and facilitated positive outcomes that mattered to all participants, despite their medical and psychosocial differences. Overall, the results demonstrated that the SEGT was effective in addressing male GI cancer patients' emotional and existential needs.

4.1. Group experience over time

Meeting or exceeding participant expectations, and negation of any adversaries, might have positively conditioned group attendance over time. This is in contrast with reports pointing to men more as “one timers” versus “regulars” in support groups.[22,23] At 6 months, findings indicated an alignment between initial interest for attendance[16] and motivations for continued engagement, which suggests that this group intervention, apart from being based on a strong supportive-expressive theoretical foundation, was meeting the continual needs of the study participants for social and emotional connectedness. This is significant in that it informs future efforts to plan theoretically sound group interventions which target and address identified needs of men diagnosed with cancer.

Despite sample variation, men consistently appreciated the supportive-expressive exchanges as helpful mechanisms for experiencing the group as a unique, sharing, normalizing, and emotionally supportive medium. These are acknowledged in the literature as universal therapeutic group attributes, constituting the inherent value of supportive-oriented group formats.[24,25] The men's consistent praising of the group's inherent value is in contrast with published findings, based mostly on research with breast and prostate cancer support groups, inferring that men feel more inclined to endorse informational or educational exchanges.[14,15] Such inferences have traditionally limited the creation of men-specific support groups that facilitate emotional expression and led to men's cancer groups being predominantly psychoeducational in nature.[26]

Our study participants joined the group in anticipation to affiliate with other men diagnosed with GI cancer for the purpose of learning about coping strategies[16] and, for the most part, were unaware or unexperienced with supportive/expressive group dynamics. It came as a surprise to most men to find how easy and useful it was to share their feelings in the group. This is in line with several studies claiming that men's initial inclinations for attending groups might evolve once they delve into group processes.[27] This finding challenges the popular belief that men are unable or unwilling to outwardly express emotions, linking such to the historic matter of hegemonic masculinity.[28,29]

Understandably, the experience with supportive/expressive exchanges had different meaning, implications, and benefits for each participant, for example, ‘altruistic’ for the ones in remission, improving mood through emotional expression, enhancing coping through learning, and sharing for the ones in the treatment phase of their illness and social bonding, solidarity, and emotional support for those with advanced cancers. This is consistent with many studies suggesting that the differential impact of group processes directly affects the value members ascribe or gain through participation.[16,24] Our findings inform those supportive-expressive mechanisms were meeting the psychosocial needs of the participants at any stage of their illness trajectory.

Another important finding relevant to the group experience pointed to the role of social comparison among the group members. It is recognized in the literature that patients with cancer may compare themselves with others to evaluate their disease, learn about treatment, and assess how well they are coping.[30] Our study participants compared themselves with others in better conditions (‘upward’ comparison) and those in worse conditions (‘downward’ comparison). Both, ‘upward’ and ‘downward’ comparison mechanisms facilitated coping, personal growth, and enhanced mood in our sample. This is consistent with the literature which suggests that social comparison dimensions improve self-appraisal and mood in cancer populations.[31,32] Other studies offer inconsistent predictions regarding benefits and risks of “upward” and “downward” mechanisms, recognizing a demoralizing effect of the latter in female cancer population receiving SEGT.[33] In our sample, feeling sad for someone who was doing worse than oneself induced empathy, positive self-evaluation, and inspired coping. The fact that no demoralizing effect was reported may be linked to the professional group facilitation which monitored and controlled the effective tone of the group in line with the SEGT protocol,[8] which in turn minimized potential negative effects of social comparison. It might as well be possible that the “no demoralizing effect” is a unique experience only for our study sample and may not generalize to others. Further investigation is needed to explore what facilitates the positive and negative functioning of social comparison mechanisms in male versus female patients attending SEGT formats.

Another important dimension of the group experience pointed to the functioning of the group format, more specifically its composition, professional facilitation, and structure. The GI tumor–specific composition, identified as a key facilitator of group uptake in a previous study with the same set of participants,[16] was experienced as an enabling mechanism for normalizing and validating shared symptomatology, treatment experiences, and similar psychosocial profiles. Several studies acknowledge the facilitating role of group compositions based on experiential similarities,[25] yet the literature offers no specific directives or “magical formula” about how to structure composition to optimize support processes and outcomes that matter to patients. Variety in GI tumor sites and stages of illness offered our participants the opportunity to understand the cancer trajectory and reflect on personal experiences. Sequentially, this very engagement process consistently fostered learning and changes in perspective, hope, and self-efficacy in our sample. This finding might offer an important consideration relevant to future group planning and delivery, particularly in a context of limited institutional resources to offer separate groups for each tumor site or stage of cancer.

Similarly, the men-only composition facilitated open discussions and emotional expressions around body function and sexuality, which otherwise, as reported by study participants, would not have been shared in a co-ed group. This is consistent with many studies indicating that men attend mixed gendered groups less regularly, and even when they do, they seem unwilling to discuss symptoms perceived as embarrassing or dive into emotional or sexual discussions about their illness.[34,35] The reported positive functioning of men-only group composition might offer useful insight and trigger clinical interest in planning men-specific socially and emotionally supportive cancer group interventions.

Most men valued the engaging and inclusive styles of the group facilitation as instrumental in making them feel comfortable to contribute and share. Engaging and inclusive styles of professional facilitation are recognized as important therapeutic factors in stimulating group interaction, cohesion, and belonging. [36] Although supportive/expressive goals framed the content of discussions, the (equally appreciated) ‘no agenda’ style of facilitation supported men to feel empowered over the process of shared narratives. This is consistent with the literature suggesting that SEGT, as a semistructured intervention, is designed to allow group members to steer the focus of the group discussions because they have the first‐hand experience with their own challenges.[17] Only four participants took up a position of critique toward facilitation pointing to four separate occasions—one man highlighted an experience when he felt that facilitators did not intervene soon enough to neutralize a negative discourse; another recalled a session where he preferred that facilitators stayed less involved in a discussion about the health system; another man pointed to a time when he felt that discussions about sexuality were redirected too soon; and another participant recalled an experience when he felt that a facilitator “dug” more than necessary. These critiques are notable in that they offer a more balanced view of the participants' experience with the group facilitation and speak to the level of comfort men felt in sharing and disclosing experience with group while being interviewed for this study. Clearly communicating the goals, approach, and process of how the group is going to function at the outset might help participants better understand why a facilitator might dig deeper on a point or not rapidly intervene to comfort participants. Facilitators, for their part, should be open and self-reflective to understand if there are occasions where their own discomfort may influence their behavior and willing to learn from participant feedback.

Regarding the functioning of the group structure, a drop-in format was preferred to a closed membership group. Similarly, the ongoing nature (“no expiry date”) of the group was found useful by all the participants. Possibly such preferences are linked to the fact that the drop-in format accommodated men's temporary nonattendance because of illness adversities, whereas the continuous running of the group offered a consistent support system for them to go back whenever they could or needed. In line with the stress and coping theory, consistency and availability of support systems facilitate mitigating distress.[37] Other group structuring elements such as frequency (biweekly) and session length (90 minutes) were equally found useful by all study participants. Reports on support groups acknowledge that participants' feedback on the structuring elements of group formats, such as length, frequency, and location, is less prone to social desirability[38] and informative in planning patient-centered group formats. Overall, findings relevant to group composition, professional facilitation, and structure might offer useful insight to inform the future formation or adaptation of supportive/expressive groups for men's cancer populations.

4.2. Perceived benefits in relation to supportive/expressive goals

The most cited perceived benefits in our sample pointed to feeling heard and validated, feeling safe to express emotions, learning from other group members about coping, and re-evaluating personal goals. Feeling heard and validated allowed participants to feel accepted, understood, and not alone. This premise supported men in being vulnerable and open in a context of safe and protected environment. The literature is consistent in proposing that feeling heard and validated allows for being open, unfiltered, and authentic.[39] Giving themselves permission to cry, feeling supported and safe to do so, and realizing its freeing effect, point to the group being a useful outlet for expressing emotions, and challenging one's own stereotypes of viewing emotional sharing as a sign of weakness.

Feeling safe to express emotions is one of the most significant benefits men gained from the SEGT intervention. This remarkable finding is in contrast with most studies about men diagnosed with cancer, claiming that men shy away from disclosing vulnerability and are reluctant to share or express emotions. [40,41] Overall, at both 3 and 6 months, participants reported that experiences with group process and intervention goals were vital in decreasing their distress levels, normalizing worries about death and dying, and re-evaluating their life priorities. These findings corroborate with our quantitative findings on the same set of participants reporting mood improvement, reduced anger, and enhanced coping.[13]

Experience with other intervention end points reflected outcomes that mattered differently to each participant. For example, patterns of improvement in communication with medical team members or in dealing with body changes (eg, living permanently with a colostomy bag) were cited as beneficial for the participants who needed support in those areas. These findings indicate that benefits from the SEGT intervention reflect a variation of adjustment demands in our sample population. Even when participants noted no personal benefit pertaining to a particular goal, they reported mood improvement when assuming a supportive role to benefit fellow members.

Our findings indicate that the SEGT intervention was perceived to be effective in addressing the men's social, emotional, informational, existential, relational issues with significant others, and adjustment needs. Clearly, study participants benefited from experiencing the group's core therapeutic processed as an “end in itself,” which by default served as a ‘means to an end’—in other words, as means to intervention psychosocial outcomes that mattered to them. Positive experience with the group's inherent value and proximal results concurred with findings from quantitative studies evaluating the efficacy of SEGT interventions.[9,18]

4.3. Study limitations

Despite interesting findings, this study has a number of limitations. Our sample was homogenous, comprising mostly of White, better-educated men; this did not allow for capturing views of culturally diverse male patients with GI cancer. There is evidence that for culturally and linguistically diverse populations, language is often a barrier to participate in these groups.[42] Although this study does not seek to generalize the findings to culturally diverse groups, it is difficult to claim whether the SEGT would benefit men from other ethnic groups such as Asians, Hispanics, or Black communities in Canada the same way as Caucasians. Another limitation was the reduced sample size at Time 2 (6 months from the time of entering the group) because of participants being lost for a variety of reasons. A bigger sample at Time 2 may have provided a richer understanding of the lived experiences over a 6-month period. The findings presented here are dependent on participants' recall and their capacity for insight and reflection. It is possible that participants attributed some changes to group participation that were actually influenced by other factors such as their response to treatment. It is noteworthy that the men who participated in our study volunteered to take part in this research and were motivated to participate as opposed to others in the group who did not agree to participate. We did not interview men who declined to participate in this study which might have provided additional useful information about their reasons for declining to participate or their apprehensions about the therapy.

5. Conclusion and implications

In the backdrop of no information of the use of supportive/expressive–oriented group interventions in men, findings of this study are vital in understanding the potential role of the SEGT in addressing emotional and existential distress in men diagnosed with cancer. This study also speaks to the potential benefit in psychosocial program planning and thinking of the opportunities of conducting men specific group programing. This study's results will be useful in informing the design and format of men-centered cancer support groups that foster emotional exploration and expressive disclosure. The findings suggest that SEGT is a valued, accessible resource within a wider system of cancer psychosocial support, particularly for efficiency and flexibility in supporting patients to achieve diverse personal goals.

Funding

This study was funded by the generous donation of Ron Curle, a former support group member, who felt that studying the GI men-only support group would facilitate group program sustainability and benefit other men diagnosed with GI cancer. The donations were administered by the Alberta Cancer Foundation. Partial funding was obtained from the Daniel Family Leadership Chair in Psychosocial Oncology.

Conflicts of interest statement

The authors declare no conflicts of interest.

The corresponding author Barry D. Bultz is an Editorial Board Member for the Journal of Psychosocial Oncology Research and Practice and has been recused from reviewing or making decisions for the manuscript. Linda E. Carlson holds the position of co-Editor-in-Chief for Journal of Psychosocial Oncology Research and Practice and has been recused from reviewing or making decisions for the manuscript.

Authors’ contribution

C. Martopullo, B.D. Bultz, and L.E. Carlson participated in study design. D.V. Oberoi and C. Martopullo participated in data analysis. D.V. Oberoi, C. Martopullo, B.D. Bultz, and L.E. Carlson participated in writing of the paper. C. Martopullo and B.D. Bultz participated in performance of the research. Ms. C. Martopullo is a psycho-oncology clinician designated to the Gastrointestinal Tumor Group in the Department of Psycho-Oncology, TBCC—Alberta Health Services, and holds an Academic Appointment as an Adjunct Lecturer in the Department of Oncology, Cumming School of Medicine, University of Calgary. Dr. D. Oberoi was a postdoctoral fellow in the Division of Psychosocial Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, at the time of study conduct and was supported by Daniel Family Leadership Chair in Psychosocial Oncology. Dr. L. Carlson is a Professor in the Department of Oncology, Cumming School of Medicine, University of Calgary, and holds the Enbridge Research Chair in Psychosocial Oncology, co-funded by the Canadian Cancer Society Alberta/NWT Division and the Alberta Cancer Foundation. Dr. B. Bultz is Professor and Head, Division of Psychosocial Oncology, Cumming School of Medicine, University of Calgary, and holds the Daniel Family Leadership Chair in Psychosocial Oncology.

Acknowledgments

We also wish to thank all the participants for agreeing to participate in this study, and the GI oncology medical team at the TBCC, specifically Dr. Scot Dowden, for supporting group enrollment.

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Keywords:

cancer, gastrointestinal cancer; men, qualitative; supportive-expressive therapy

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