Br. J. med. Psychol. (1976), 49, 257-260 Printed in Great Britain
Group psychotherapy in the management of bronchial asthma* BY M. W. FORTH
Bronchial asthma is a common and potentially dangerous disorder, complex in its aetiology and incompletely understood. Its symptomatology results from the release of oversensitivebronchoconstrictor mechanisms by a wide variety of stimuli and their causal relevance is uncertain and widely disputed. Thus, a controlled research study by Zealley, Aitken & Rosenthal(1970)and a more recent study by Benjamin (1974) led them to conclude that asthmatics have no greater incidence of neurotic disorder than the general population, and they suggested that the emotional factor was a somato-psychic one and not primarily aetiological. These careful and convincing studies however may at first sight seem to contradict the general clinical view of the importance of psychological factors in asthma. Approaching the subject from a psychoanalytical point of view we find no incompatibility between these findings and the idea of psychological factors being of the greatest importance in some cases of asthma. In order to investigate this matter further we conducted an open psychotherapeutic group of asthmatic women over a period of 18 months. This work was done in the framework of a psychosomatic discussion seminar conducted at King’s College Hospital and reported elsewhere (Jackson, 1973). In this paper we present a condensed account of our approach and findings, illustrating some of the difficulties we encountered and some of the therapeutic potential of this sort of work. We conclude with some suggestionsthat might account for the wide variation in therapeutic results reported by other workers. This study is an impressionistic one, and our wish is to promote discussion and to encourage others, who have the opportunity, to explore the considerable psychotherapeutic possibilities in the field. THEORETICAL APPROACH
Our theoretical approach is psychoanalytical and psychobiological, in that neurotic, delinquent and psychotic symptomatologies are seen basically as attempts to cope with the pain of mental conflict. When these mechanisms fail extremes of biological arousal of a defensive nature occur which, in the presence of local vulnerabilities, lead to functional changes and ultimately to tissue damage. In this view [corresponding with that of Engel (1%2)] psychological stress may act as a contributory causal factor (sometimes of primary importance) without being either necessary or suficient. ‘Somatization’ may thus occur in a spectrum of personalities. At one extreme is the normal personality with varying degrees of biological vulnerability in whom stress may or may not be a factor, at the other there is significant, and at times severe, psychopathology. We believe, as do others, that the psychopathology tends to be rather specific and involves an excessive use of denial as a ‘last ditch’ defensive measure. This phenomenon has led Sifneos (1972) to coin the term ‘alexithymia’ to describe the severe difficulty these people have in recognizing and handling affects, of translating tension states into manageable psychologically represented awareness, and of using the normal scanning and monitoring functions of the ego. Our group was near the latter end of this spectrum of severity, having been referred by *
Paper read at 10th European Conference on Psychosomatic Research, Edinburgh, September, 1974.
t King’s College Hospital, Denmark Hill, London SE5 9RS.
M. W. F O R T H A N D M . JACKSON
physicians who detected fairly obvious psychopathology and is thus not at all representative of asthmatics as a whole. Of the 11 patients who attended the group 6 dropped out after a few sessions and a nucleus of 5 continued throughout. THERAPEUTIC METHOD
The patients were referred from the hospital’s Asthma Clinic. They were all married, with the exception of one who dropped out after two sessions. They were aged between 30 and 60,mostly had severe asthma, with multiple episodes of hospitalization and steroid medication. They were early and late onset cases, and most had a great deal of pathology in their marriages and families, and history of considerable childhood stress. (Seven of the 11 had lost their fathers, through death or divorce, in childhood.) During the course of the group many were hospitalized for relatively brief periods, which created problems of communication and management with the Asthma Clinic, despite our basically good relations with the physicians involved. The group met weekly for 1% hours, and the two authors were co-therapists. Our techniquewas conventional insight-directed, aimed at detecting and interpreting basic problems of communication in the here and now of the current group relationships. This involved the sorting out of those transactionswhich were reality based (non-transferential) from those which were the expression of unresolved conflicts of the past (transferential). In order to convey in a limited time something of the processes we observed, we wish to comment on the high dropout rate of nearly 50 per cent. Since many people have found subjects with major psychosomatic disorders remarkably difficult to engage in psychotherapy, we have given this matter much thought. We feel that the most obvious factors such as inadequate referral methods and insufficient therapist skill did not fully account for this phenomenon, and we delineated the following areas of difficulty: (1) The fear of engagement as an expression of extreme fears of dependency. (2) Insight seen as a threat to a basically brittle and precarious adjustment. (3) The splitting of care resulting from attendance at the Asthma Clinic and hospitalization. (4) Antagonism of spouses to the therapeutic project. (5) The infrequency of sessions. Patients often commented on their fear of feelings emerging and having to cope with them alone for a \(reek, and expressed a preference for two sessions a week. This was not possible for reasons of available time. (6) The individual defensive structure, based on denial, as already mentioned. This feature was repeatedly observed, sometimes dramatically. Thus, one patient, after several months of attendance, took a fortnight’s holiday abroad. She was free from asthma throughout except for the hour of the group session each week, when she had a severe attack. Despite this she was totally unable to connect the ‘separation’ implications of this in anything but an intellectual way. On the other hand, we also found that after a long period some patients became much more able to find their feelings. One discovered to her surprise that, for the first time in her marriage, she missed her husband when he went abroad and was concerned for his safety. Despite these difficulties we were encouraged by the improvement in several of our patients. It was not possible to evaluate this because of intercurrent events such as changes in medication. However, most of the patients were referred because they were not improving and we repeatedly observed that attacks were precipitated by psychological stress, particularly by life situations in and out of the group that mobilized separation anxiety. By the end of the group, several patients had become more aware of conflict and anxiety, had less asthma, and in terms of our approach could be said to be becoming more capable of ‘mentalizing’ their conflicts and thus moving in the direction of normality. Early on we made regular spirometricrecordings with a Peak Flow meter, and issued the patients with diary and self-assessmentcards. However, these proved of little use for our particular purposes and we abandoned them. We found that both measures were too crude to reflect the more subtle factors which we thought were important. Thus, transient wheezing in the session did not register on the post-session spirometry and patients usually recorded only trite events in their daily lives (which we regarded as a manifestation of denial). DISCUSSION
In considering this group we have been led to speculate about some striking differences in the reported outcome of group therapy with asthmatics. Particularly interesting is the good record of asthma remission, obtained by Groen & Pelser (IW),contrasted with the personality improvement, but little impact on the course of asthma, recorded by Sclare & Crockett (1957). We cannot be sure what led to this difference but think it noteworthy that whereas Sclare &
Group psychotherapy in bronchial asthma
259 Crockett concentrated their attention on group interaction, Groen & Pelser made themselves, as physicians, responsible also for physical examination and treatment. It is characteristic of the dynamic forms of psychotherapy that they use and encourage awareness of the evolving tensions between the curing and challenging roles of the therapist. In the context of warmth, acceptance and care, the patient is supported in using his ego strength to meet the challenge posed by interpretationsand clarifications.We suggest that some asthmatic patients have learned a method of eliciting concrete caring responses without becoming aware of their dependency needs, thus avoiding the fear of rejection by a figure in the environment emotionally equivalent to the child’s mother who has been experienced as unwilling or unable to accept, tolerate and contain the infant’s powerful feelings - aggressive, sexual or depressive. This concept seems to fit well with that of ulexithyrniu already mentioned and explains why some patients reject psychotherapy which is more than merely supportive. We wonder whether some asthmatic subjects can only respond to care in a very concrete form. This is not to suggest that they lack real care but that they may lack care in a form they can accept and acknowledge. I would like to illustrate this problem with a dramatic fragment from our own group experience. Mrs T., a 35-year-oldhousewife, the most severely asthmatic subject of the group, had suffered repeated attacks of status asthmaticus for 15 years, necessitating hospital treatment. She also exhibited some evidence of depression and some quite severe phobic symptoms. Despite her physical ill-health she was a regular group attender and after nine months had achieved some insight into and resolution of her phobic difficulties. At this point she arrived for a session quite severely breathless and looking extremely ill. At first the group ignored her distressand continued with their comfortable often-aired topic of how difficult, bad-tempered and destructive was the behaviour of key individuals in their environment. Mrs T. meanwhile grew worse and started to look grey and shocked as she laboured to breathe. Her distress soon reached a level at which it became necessary for one of the therapists to escort her from the room. Once outside she was looked after by a lady colleague while skilled medical aid was sought. Unconstrained by the formality of the group setting this colleague was able to respond spontaneously by putting her arm around Mrs T. and gently urging her to give way and express her feelings. After a short period of increasing bronchospasm (and expression of feelings of guilt and worthlessness) Mrs T. suddenly burst into a flood of racking tears. Soon her breathing was almost normal and she insisted that she did not want to talk further one-to-one but wished to return to the group. The dramatic change in her physical state surprised us despite our familiaritywith the transient benefit of catharsis and stretched the credulity of the group, who would not believe that she had not been given intravenous steroids or bronchodilators during her absence. Equally surprising was the fact that she remained totally symptom-free for the next 12 months. This vignette proves nothing but could be seen as support for the idea that more concrete physical caring may have a powerful psychotherapeutic effect that requires further investigation. CONCLUSIONS
No really firm conclusions can be drawn from a brief clinical study of this sort, but some tentative generalizations can usefully be offered. In a significant, but unknown, proportion of asthmatic subjects psychological factors play an important causal role. Such subjects may be peculiarly difficult to engage in psychotherapy, a phenomenon that may be typical of many types of psychosomatic disorder (see Sifneos, 1972). The high drop-out rate that we encountered may be characteristic of this type of patient, and suggests that modifications of conventional once-weekly psychotherapy merit exploration. Since these patients seem to have specific difficultiesin finding and working through certain fundamental feelings, the therapeutic process is likely to be extremely difficult and prolonged. More frequent
M. W. FORTH A N D M. J A C K S O N
group sessions, or the combination of group and individual therapy sessions may prove to be more effective. The use of psychodrama and encounter techniques may possibly have real importance in this field (see Reckless, 1972). However, there is evidence that such patients are particularly prone to acting-out behaviour (see Sperling, 1%8) and such explorations should be in the hands of therapists who are experienced and highly skilled in these techniques. What we have referred to as ‘concrete physical caring’ may have played a part in the good results reported by Groen & Pelser. This suggests that asthma may be one condition where the medical psychotherapist may, as a considered technique, step out of his conventional role and undertake concurrently the physical care of the patient, under appropriate supervision. The important symbolic significanceof the provider of medication, and particularly the use of aerosol inhalants could perhaps be better investigated in such a context. The experiencewe report here has been limited but has convinced us that group psychotherapy with selected asthmatic subjects is a valuable research instrument, of considerable therapeutic potential, and that it has an important, and relatively unacknowledged part to play in the management of this common and disabling disease. SUMMARY
In this paper the authors present their theoretical view of the place of psychogenic factors in asthma. They review the experience they had in conducting weekly analytically orientated group therapy with a group of asthmatic women for 18 months and review the difficulties they met in this work. From this experience they attempt to reconcile some of the contradictions in previously published work in this area. ACKNOWLEDGEMENT
We are most grateful to Dr Dennis Brown for his helpful comments. REFERENCES
BENJAMIN, S. (1974). Asthma and mental illness: A 15 year follow-up study. Paper read at 10th European Conference on Psychosomatic Research, Edinburgh. ENGEL,G. W . (1%2). Psychological Development in Health and Disease. Philadelphia: Saunders. GROEN,J. J. & PELSER, H.E. (1960). Experience with group psychotherapy in patients with bronchial asthma. J. psychosom. Res. 4, 191-205. JACKSON,M. (1973). Proc. 9th Eur. Conf. Psychosom. Res. London: Karger. RECKLESS,J. F. (1972). Groups, spouses and hospi-
talization in a trial of treatment in psychosomatic illness. Psychosomatics 13, 353-357. CLARE, A. B. & CROCKE’IT,J. A. (1957). Group psychotherapy in bronchial asthma. J. psychosom. Res. 2, 157-171. SIFNEOS,P. E. (1972). The prevalenceof alexithymic characteristics in psychosomatic patients. Topics of Psychosomatic Research. London: Karger. M.(1968). Acting out and psychosomatic SPERLING, symptoms. Int. J. Psycho-Analysis 49. 25&253. ZEALLEY,A. K.,AITKEN,R. C. B. & ROSENTHAL, S. U. (1970). Asthma: A psychophysiological investigation. Proc. R. SOC.Med. 64, 825-829.