The Fourstage Intervention

The first intervention occurs before the patients ever arrive and involves the therapist paying attention to the medical comfort needs of the patients. Patients with compromised immune systems may need to have bottled water available. Patients on multiple medications may need to have snacks to take medication during the group time, and they may need to have a convenient bathroom easily available. Patients may not be able to walk stairs or navigate large parking garages.

In the second intervention, the therapist sets the safety parameters by outlining that the group will be addressing difficult issues and personal stories. Confidentiality will be expected and individual members and their stories will be respected. Sometimes a written confidentiality contract will be signed by the patients. In addition, the therapist also needs to pledge to respond honestly to situations. For example, if dementia or a loss of cognitive functioning is a possible outcome of the disease or the treatments, the therapist needs to be the one person who agrees to discuss honestly what he or she observes and not surrender to platitudes like "everything is fine." Establishing safety and trust are of paramount importance in working with this population.

The third intervention involves having the clients introduce themselves, their diagnoses, and give some medical information or update, and psychosocial history, almost every session. It is important to have clients state their diagnoses and some understanding of what is involved with that diagnosis, whether it is considered treatable or not. For many group members, this is the only place they can talk openly, without shame or blame (if they have HIV/AIDS, or lung cancer),

Living with Dying

without embarrassment (if they have prostate or anal cancer), and without "helpful" family members trying to insert their own comments.

The fourth intervention is active listening, reflecting back to the patients what they are saying and how they are feeling. The therapist should be nonjudgmental, open and accepting. The therapist should help members find a sense of belonging and connection. The leader should be able to guide the process of disclosure, be somewhat knowledgeable about the disease and treatment, and most importantly, be able to shift the discussion from the factual content of the disease and its treatments to the process of living and perhaps dying, with all the attendant emotions.

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