Table 3 Intervention program
Session 1 Psychoeducation and normalization of emotional reactions |
Objectives: • Accept the negative reactions (e.g. fear, anxiety, anger, hopelessness, guilt, shame or confusion) as natural responses to the disease and understand the ambivalence between positive and negative feelings related to the personal experience of breast cancer. • Enhance the knowledge related to breast cancer, including, definition and disease progress, treatments, side effects and other procedures related to the disease. Activities: • “Emotions’ cards” – Each participant has to choose 6 cards from the total of cards with positive and negative emotions to illustrate which emotions that each participant felt during their own experience of breast cancer. This activity ends with a group discussion about the dichotomy between positive and negative emotions. • Psychoeducation – Psychologist provides information about breast cancer, including various topics. • Self-report measure – Each participant completes the questionnaire of basic beliefs [49]. |
Session 2 Facilitating emotional disclosure and communication |
Objectives: • Increase emotional expression during breast cancer and practice communication skills for a well-adjusted expression of emotions and experiences related with breast cancer. Activities: • “Communication’ cards” – Each participant has to choose one set of cards that illustrate one hypothetic situation that address any communication issue. Each set of cards is composed by the situation, the positive and negative behavior, and the positive or negative outcome from the behavior. This activity ends with a group discussion about communication strategies and ways to promote an assertive style of communication. • Self-report measure - Each participant completes the Distress Disclosure Index (DDI) [57] and the Opener Scale [58, 59]. |
Session 3 Practice emotional self-regulation skills |
Objectives: • Development of an adjusted stress management of individual emotions and reactions related to the disease, based on a more adaptive coping style. • Promote an autonomous use of self-regulation techniques. Activities: • Self-regulatory strategies for stress management – The psychologist introduces and promotes the practice of abdominal breathing and progressive muscle relaxation at the end of this session. |
Session 4 Fears and concerns related to breast cancer |
Objectives: • Improve the personal skills to an adjusted expression of concerns and expectations about the future, including, disease progression, treatment and even practical and financial concerns. Activities: • Rational Emotive Behavior Therapy [62] – Participants are invited to write their intrusive thoughts related with breast cancer and to write personal strategies to transform intrusive thoughts into deliberate thoughts. • Mindfulness – Psychologist introduces and promotes the practice of mindfulness exercises as a useful technique to change the intrusive thoughts. |
Session 5 Balance between gains and losses after breast cancer diagnosis |
Objectives: • Improve the balance between benefits and losses and the perception about the ambivalence between positive and negative feelings from the experience of breast cancer. Activities: • Balance of gains and losses – Each participant is invited to write their gains and losses in several areas of women's lives, as a result of their personal experience of breast cancer. A group discussion about the number of losses and gains reported by the group is promoted, at the end of the activity. • Challenge of core beliefs – To encourage the perception of possible changes in core beliefs, each participant is invited to wonder about core beliefs that she had before the diagnosis of breast cancer and that have been changed, as a result of the breast cancer experience. |
Session 6 Construction of a coherent personal narrative |
Objectives: • Construction of an individual narrative, to understand and integrate the experience of breast cancer in the set of the woman's life events [63]. • Promote the use of the expressive writing technique after the end of the intervention. Activities: • Expressive Writing - The group members received the following instructions: "Please indicate how breast cancer changed you and your personal life story". Promote group discussion about this topic. • Introduce expressive writing technique, its definition, objectives, and instructions. Each participant receives instructions for the expressive writing task along with all the materials required to perform this task at home. The written material is returned in the next session. The written information is confidential. All questions and doubts about this writing technique are clarified. The model used is according to Pennebaker [63], and the procedures are adapted from group interventions developed with cancer patients [60, 61]. |
Session 7 Development of new values and priorities of life |
Objectives: • Expand the cognitive processing about core beliefs and personal values to achieve the redefinition of life priorities and the reevaluation of personal objectives, which are now consistent with the perceived identity changes. Activities: • “Reflection about principles of life” – Each participant is encouraged to recognize the previous principles of life and the new principles and objectives of life, more suited to the current reality, by answering the following question: "Please reflect on the principles of life that you have used through your life, until the present time." |
Session 8 Redefinition of objectives and life goals |
Objectives: • Redefinition of new life goals according to the actual personal narrative, which implies the rupture with the previous objectives, might occur, to give rise to life values more adjusted to the new reality and the current knowledge. Activities: • “Redefinition of life goals” – Participants are invited to write objectives, eventual obstacles and plan of action to achieve the objectives that they intend to achieve at medium or long-term. • “Problem-solving technique” – Psychologist introduces the problem-solving technique and promotes the development of problem-solving skills. • Self-report measure – Each participant completes the questionnaires from the second evaluation moment as well as a questionnaire to evaluate the intervention program. |