The Psychosocial Treatment Laboratory has been engaged in systematic evaluation of group psychotherapy for breast
cancer patients since 1975. This led to further studies of the application of supportive-expressive psychotherapy
in patients with lymphoma, bone marrow transplant, prostate cancer, cardiac arrhythmia, and HIV. Additionally,
the laboratory is studying the use of hypnosis as a complementary intervention for unusual psychological states
such as dissociative disorders and post-traumatic stress disorder (PTSD). To this end, the relationship of physiological
activity such as brain waves, heart rate, muscle tension and hormone levels in the blood during hypnosis, and physiological
and psychological changes in the aftermath of traumatic events have been investigated.
Cancer Related Research
- Improved psychological well-being: the effects of group therapy in reducing mood disturbance
and pain among metastatic breast cancer patients
- Effects of supportive-expressive group psychotherapy on survival time and medical outcome
(The Original Metastatic Breast Cancer Survival Study)
- Effects of group psychotherapy on endocrine and immune function in metastatic breast
cancer patients and their spouses
- Studies of therapist training and adherence to supportive-expressive therapy protocol
- Multi-center randomized prospective trial of supportive/expressive group psychotherapy
for patients with primary breast carcinoma
- Supportive-Expressive Group Intervention for Women with Increased Risk for Breast Cancer
- Pilot Study: Impact of Intervention for Heritable Breast Cancer Risk
- A Multicenter Trial of Group Therapy for Breast Cancer
- Cancer Support and Quality of Life at The Wellness Community
Improved psychological well-being: the effects of group therapy in reducing mood disturbance and pain among
metastatic breast cancer patients.
Group therapy intervention for metastatic breast cancer patients can significantly reduce mood disturbance (Spiegel
et al, 1981) and pain (Spiegel & Bloom, 1983). Treatment techniques included expression and management of disease-related
affect, reinforcing social support, improving communication with physicians, and a self-management strategy which
was taught for pain control (Spiegel & Yalom, 1978; Spiegel, 1985). This experience forms the basis for the
current intervention model with women at risk for cancer.
Effects of supportive-expressive group psychotherapy on survival time and medical outcome (The Original
Metastatic Breast Cancer Survival Study)
Funding: National Cancer Institute
We have shown in a randomized prospective trial that supportive-expressive group psychotherapy intervention
not only improved the quality of life but unexpectedly affected its quantity as well. The intervention lasted for
a year while both control (N=36) and treatment (N=50) groups received their routine oncologic care. These data
were published in The Lancet (Spiegel et al, 1989, see Abstract). We
had undertaken this ten-year follow-up study with the belief that such positive psychological and symptomatic effects
could occur without affecting the course of the disease. As it turned out, there was a striking difference between
control and treatment groups in length of survival from time of randomization until date of death. Survival time
for the treatment group was 36.6 (sd = 37.6) months compared with 18.9 (sd = 10.8) months for the control group.
It thus appears that randomization to psychosocial support may have resulted in a statistically and clinically
significant increase in survival time.
Effects of group psychotherapy on endocrine and immune function in metastatic breast cancer patients and
Funding: Fetzer Institute; John D. and Catherine T. MacArthur Foundation
In collaboration with Professor Judith Rodin (President, University of Pennsylvania), we have developed a means
of assessing the influence of emotional distress on immune function in patients and their spouses. Couples are
asked to generate and rank order a list of cancer-related problems in their relationship, a generally stressful
task. In collaboration with Professor Daniel Stites (University of California, San Francisco), participant immune
function and reactivity is measured through blood samples collected during the task, and tested for natural killer
cell number and cytotoxicity and CD4/CD8 counts. Our pilot data in this study reveals that natural killer cell
function is depressed during this stressful interaction, and rebounds within 24 hours. We predict participation
in (patient or spousal) supportive-expressive group therapy will buffer the physiologic effects of emotional distress,
and correlate with better coping mechanisms and improved medical outcome.
Studies of therapist training and adherence to supportive-expressive therapy protocol:
Funding: Nathan Cummings Foundation
Training: Over the past two years, we have trained six therapists to lead supportive-expressive therapy groups
of primary breast cancer patients: 2 M.D. psychiatry residents; 2 licensed social workers in practice; 1 each Ph.D.
psychologist (unlicensed) and pre-doctoral licensed psychotherapist. These therapists were trained at different
times, and with varying degrees of training, affording us an understanding of the minimum type of training required
before sufficient competency can be achieved. We have developed a training manual , and videotapes of groups in
order to demonstrate and teach the principles involved in this therapy, which are frequently at odds with classical
psychotherapy training. The videotapes are used to assess learning in newly trained therapists by having them 1)
review previously rated tapes; 2) identify the core psychological or cancer focus and 3) select an appropriate
See also, Brief Supportive-Expressive Group Therapy for Women with Primary Breast
Cancer: A Treatment Manual.
Multi-center randomized prospective trial of supportive/expressive group psychotherapy for patients with
primary breast carcinoma.
Collaborators: Gary Morrow, Ph.D., University of Rochester; Community Cooperative Oncology Program of the NCI;
Nathan Cummings Foundation
Funding: National Cancer Institute
This is a prospective randomized trial of group psychotherapy in primary breast cancer patients in 12 centers
across the nation. Assessment of support, coping, psychological distress as well as well as outcome enables to
determine intervention effects. The range of centers provides an empirical basis for widespread programmatic implementation
of psychosocial intervention in breast cancer patients. In order to develop a standardized training program, we
trained 24 therapists to conduct groups at the various sites. 120 patients participated in 12 week group psychotherapy,
as well as completing baseline and follow-up psychological assessments. These data are currently being analyzed.
We are now in the process of recruiting 240 women at the 12 centers for randomization. The issue of dealing with
anticipatory anxiety regarding surveillance and testing is a major portion of the treatment intervention and is
comparable to the experience of women at risk for breast cancer.
Supportive-Expressive Group Intervention for Women with Increased Risk for Breast Cancer:
Funding: Institut Curie, Paris, France
Currently underway, this new study is a six-month study of the application of supportive/expressive group therapy
to women at high genetic risk for breast cancer. Dr. Gilles Thomas from the Institut Curie in Paris, is examining
a cohort of 200 women with family histories of breast and ovarian cancer for the presence of the BrCA1 gene, and
are providing genetic counseling to these women. A pilot study of 10 elgible women met weekly with Dr. Spiegel
and psychologist Dr. Sylvie Schwab for 12 meetings. In this group the emotional issues surrounding having breast
cancer, and having inherited and transmitting genetic risk for cancer, are being explored.
Pilot Study: Impact of Intervention for Heritable Breast Cancer Risk
Funding: National Cancer Institute
In order to test alternative models of delivering risk assessment and support, we are beginning a randomized
prospective pilot comparison study of 40 women with elevated breast cancer risk: one-half of whom will receive
individualized cancer risk counseling while the other half will receive cancer risk counseling plus supportive-expressive
The purpose of the study is to:
- identify psychosocial distress, particularly risk-related anxiety
- evaluate alternative models for delivering psychosocial support to minimize that distress and
- determine whether education and intervention can affect preventive health beliefs and behaviors.
A Multicenter Trial of Group Therapy for Breast Cancer
Principal Investigator: David Spiegel, M.D.
Co-Investigator: Gary Morrow, Ph.D.
Project Director: Catherine Classen, Ph.D.
Funding: National Cancer Institute, Nathan Cummings Foundation
This is a community-based, randomized, prospective multicenter trial examining the effectiveness of a supportive-expressive
group therapy model (developed and tested in our laboratory) for women recently diagnosed with primary breast cancer.
This study addresses the utility of supportive interventions in the 'real world' community setting through assessment
of its results in 9 Community Clinical Oncology Program (CCOP) practices and 2 university sites. It began on July
1, 1993 and data collection ended June 1998.
There were three primary aims:
- To demonstrate the effects of a supportive-expressive group therapy intervention on mood disturbance, attitudes
and beliefs about cancer, social support, and treatment adherence. It was hypothesized that women who are randomly
assigned to support groups will show less mood disturbance, and better adherence with medical treatment.
- To identify the subsets of patients who are most likely to benefit from the intervention. It was hypothesized
that patients with higher initial levels of mood disturbance and poorer social support would benefit more than
other patients from participation in group therapy.
- To determine whether this method could be taught efficiently and effectively to oncology nurses and mental
health professionals. It was hypothesized that the methods involved in this supportive-expressive group psychotherapy
were transferable to the community setting by showing that community mental health care therapists can be effectively
trained. Their degree of skill and adherence to the protocol was hypothesized to be predictive of reduced mood
disturbance and better treatment adherence among breast cancer patients.
The results of this study are presented in the following publications:
Classen, C., Koopman, C., Atkinson, A., DiMiceli, S., Morrow,
G., & Spiegel, D. (in preparation) Group Therapy for Primary Breast Cancer Patients: A Randomized Prospective
Classen, C., Giese-Davis, J., Angell, K., Gore-Felton, C.,
Michel, B., Brennan-O’Neill, Morrow, G., & Spiegel D. (in preparation). The delicate balance of coping with
primary breast cancer: Expressing emotion while maintaining a fighting spirit.
Durán, R., Classen, C., Atkinson, A., Morrow, G., Pierce,
H.I., Hart, R. & Spiegel, D.. (in preparation). Considering the source: Social support and the emotional adjustment
of women diagnosed with primary breast cancer.
Koopman, C., Drescher, K., Bowles, S., Dondershine, H., Classen,
C. & Spiegel, D. (in preparation). Acute dissociative symptoms in veterans with PTSD.
Kato, P.M., Classen, C., Morrow, G., & Spiegel, D. (in
preparation) Supportive-expressive group therapy for women with primary breast cancer: A signal detection analysis
of improvement over time.
Koopman, C., Butler, L., Classen, C., Giese-Davis, J., Morrow,
G., Westendorp, J., Banerjee, T. & Spiegel, D. (in submission). Post-traumatic stress symptoms among women
recently diagnosed with breast cancer.
Giese-Davis, J., Koopman, C., Butler, L., Classen, C., Morrow,
G., et al. (in submission). The development and evaluation of the Stanford Self Efficacy in Coping with Cancer
Spiegel, D., Morrow, G.W., Classen, C., Raubertas, R., Stott,
P.B., Mudaliar, N., Pierce, H.I., Flynn, P.J., & Heard, L. (in press). Group psychotherapy for recently diagnosed
breat cancer patients: a multicenter study.
Classen, C., Abramson, S. Angell, K., Atkinson, A., Desch C.,
Vinciguerra, V.P., Rosenbluth, R.J., Kirshner, J.J., Hart, R., Morrow, G., & Spiegel D. (1997). An examination
of a training program for leading supportive-expressive groups with breast cancer patients. Journal of Psychotherapy
Practice and Research, 6(3), 211-218.
Spiegel, D., Morrow, G.R., Classen, C., Riggs, G., Stott, P.B.,
Mudaliar, N., Pierce, H.I., Flynn, P.J., & Heard, L. (1996). Effects of group therapy on women with primary
breast cancer. The Breast Journal, 2(1), 104-106.
Cancer Support and Quality of Life at The Wellness Community
Principal Investigator: Dr. David Spiegel
Project Director: Janine Giese-Davis, Ph.D.
Funding: The Charles A. Dana Foundation
The purpose of this grant is to do a first-time observational study to evaluate national support programs provided
by The Wellness Community. Outcomes for people with cancer who participate in support groups were compared with
those who attend only educational programs
Hypnosis Brain Imaging Studies
- Lateralized effects of hypnosis versus selective inattention on visual perception using Brain
Electrical Activity Mapping
- Effects of Hypnotic Visual Illusion on Color Processing in the Brain Using Positron Emission
Lateralized effects of hypnosis versus selective inattention on visual perception using Brain Electrical
The psychophysiology unit of the Spiegel laboratory conducts scientific investigation into the relationship
of physiological activity such as brain waves, heart rate, muscle tension and hormone levels in the blood during
hypnosis and unusual psychological states. In normal healthy humans the effects of hypnosis on perception are being
studied by looking at evoked potentials. Evoked potentials are short duration electrical brain wave fluctuations
caused by external physical stimuli. The unit has found changes in evoked potentials which indicate the action
of hypnotic suggestion upon the perception of visual stimuli. The unit is extending its research with evoked potentials
and hypnosis into auditory and touch perception. Alterations by hypnotic suggestion in brain wave response to touch
would indicate that hypnosis has the potential to actually diminish the activity in pain-signaling nerve fibers.
Such an affect would be due to changes in pain fiber conduction imposed from higher nervous centers.
The psychophysiology unit also looks at the level of stress hormone (adreno-corticotrophic hormone or ACTH)
in the blood of healthy individuals during hypnotic relaxation. Reduction of ACTH levels by hypnosis would indicate
that relaxation techniques can be used to reduce the impact of daily stress upon health. Studies are also being
conducted which look at the use of hypnosis to reduce responses in heart rate and sweat glands to startling stimuli.
These responses are from target end-organs of the sympathetic (“flight or fight”) nervous system. This system is
activated by stress and overactivity in this system can lead to cardiovascular disease such as stroke or heart
attack. Reduction of activity in this system by hypnosis or other relaxation techniques could reduce the risk of
The unusual psychological states studied by the unit come under the heading of dissociative disorders. These
disorders are considered to occur as a consequence of psychological trauma such as wartime combat or childhood
sexual abuse. They are considered a defense mechanism against painful memories and can range from conscious avoidance
in their milder forms to multiple personalities in extreme cases. Dr. Spiegel has theorized that all dissociative
disorders involve splitting off from awareness of painful memories and are thus a kind of self-hypnosis. The psychophysiology
unit is studying the characteristics of healthy individuals who respond well to hypnosis and patients with dissociative
disorder to see if there are underlying commonalities and how dissociative disorder can be treated or managed.
Another psychological disorder under study by the unit is post-traumatic stress disorder (PTSD), often seen in
veterans of wartime combat. PTSD is the persistence of the flight of fight response to dangerous situations long
after they have happened and is thought to involve induced hyperactivity of the sympathetic nervous system.
The psychophysiology units plans for future research involve computer detection of specific brain wave events
which can be consciously controlled. This would allow individuals to mentally direct the operation of machines
and could be used for a variety of purposes from piloting complicated aircraft to prosthetic devices for people
with paralyzed musculature. Such research would open up new areas of a triple mind-body-machine interface and would
be the effector muscle complement of sensory virtual reality.
Effects of Hypnotic Visual Illusion on Color Processing in the Brain Using Positron Emission Tomography (PET)
Trauma Related Research
- A Study of Acute and Post-Traumatic Stress Reactions to a Highly Stressful Event
- A Pilot Study Comparing Two Models of Group Therapy for Women Abused in Childhood
A Study of Acute and Post-Traumatic Stress Reactions to a Highly Stressful Event
There is considerable evidence that dissociative symptoms are prominent in the response of individuals undergoing
physical trauma and in its immediate aftermath. They serve as a defense against pain, fear, helplessness, and panic,
providing a welcome feeling of detachment from a terrifying physical reality and the emotions associated with it.
This sense of detachment includes depersonalization, derealization, numbing of responsiveness, and other alterations
in perception and memory. Using this protocol, we have studied immediate response to the Loma Prieta Earthquake,
the Oakland-Berkeley Firestorm, the shooting at 101 California Street, and the response of journalists to witnessing
A Pilot Study Comparing Two Models of Group Therapy for Women Abused in Childhood
Principal Investigator: David Spiegel, M.D.
Co-Principal Investigator: Cheryl Koopman, Ph.D.
Project Director and Co-Investigator: Catherine Classen, Ph.D.
Funding: National Institutes of Mental Health
The purpose of this pilot study is to address the following questions regarding survivors of childhood sexual
abuse (CSA): Is it helpful to focus on survivors' memories of CSA in order to reduce distress and improve functioning?
What mediates treatment effectiveness for CSA survivors? This randomized clinical intervention trial compares trauma-focused
group psychotherapy against a present-focused group psychotherapy and a wait-listed control condition. We recruited
58 adult women CSA survivors through newspaper advertisements and local community organizations. Participants were
randomly assigned to receive group therapy immediately or to wait 6 months and were randomly assigned to receive
either trauma-focused group therapy or present-focused group therapy. Participants were assessed at baseline and
at 6- and 12-months to evaluate the effectiveness of trauma-focused treatment against the present-focused treatment
and the wait-listed control condition in reducing posttraumatic stress and other trauma symptoms and improving
interpersonal functioning. This study was funded by an NIMH award (MH52134) from September 1996 to December 1998.
See the publications listed below for the results of this study and of earlier pilot studies.
Classen, C., Koopman, C., Nevill-Manning, K., & Spiegel,
D. (2002). A preliminary report comparing trauma-focused and present-focused group therapy against a wait-listed
condition among childhood sexual abuse survivors with PTSD. Journal of Agression, Maltreatment and Trauma, 4(2), 265-288.
Field, N., Classen, C., Butler, L.D., Koopman, C., Zarcone,
J. & Spiegel, D. (2001) Revictimization and information processing in survivors of childhood sexual
abuse. Journal of Anxiety Disorders, 15, 1-11.
Classen, C., Nevo, R., Koopman, C., Nevill-Manning, K., Gore-Felton,
C., Rose, D. & Spiegel, D. (in press). Life stress and trauma symptoms in women sexually abused in childhood. Journal of Interpersonal Violence.
Koopman, C., Gore-Felton, C., Classen C., Kim, P. & Spiegel, D. (in press). Acute stress reactions to everyday stressful life events among sexual abuse survivors with PTSD. Journal of Child sexual Abuse.
Classen, C., Field, N., Koopman, C., Nevill-Manning, K. &
Spiegel, D. (in submission). Interpersonal problems and their relationship to sexual revictimization in women sexually
abused in childhood.
Classen, C., Field, N., Atkinson, A. & Spiegel, D. (1998).
Representations of self in women sexually abused in childhood. Child Abuse and Neglect,.22(10), 997-1004.
Koopman, C., Gore-Felton, C.G., & Spiegel, D. (1997).
Acute stress disorder symptoms among sex abuse survivors
seeking treatment. Journal of Child Sexual Abuse, 6, 3,