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Social Work with GroupsPublication details, includinginstructions for authors and subscriptioninformation:http://www.tandfonline.com/loi/wswg20

National TelephoneSupport GroupsLori S. Wiener PhD a , Elizabeth DuPontSpencer MSW b , Robert Davidson ACSW c

& Cynthia Fair MSW, MPH ba Coordinator, Pediatric HIV PsychosocialSupport Program, National CancerInstituteb Clinical Social Worker, NationalInstitutes of Healthc Senior Social Worker, NationalInstitutes of HealthPublished online: 18 Oct 2008.

To cite this article: Lori S. Wiener PhD , Elizabeth DuPont SpencerMSW , Robert Davidson ACSW & Cynthia Fair MSW, MPH (1993) NationalTelephone Support Groups, Social Work with Groups, 16:3, 55-71, DOI:10.1300/J009v16n03_05

To link to this article: http://dx.doi.org/10.1300/J009v16n03_05

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National Telephone Support Groups: A New Avenue

Toward Psychosocial Support for HIV-Infected Children

and Their Families Lori S. Wiener

Elizabeth DuPont Spencer Robert Davidson

Cynthia Fair'

ABSTRACT. The complexity of psychosocial needs that HIV-infected children and their families confront makes innovative approaches for p u p support a necessity. In response, National Telephone Support Groups were developed for children, non-infected siblings, infected and noninfected mothers, infected and non-infected fathen, foster parents and grandparents. As each p u p was recorded and banscribed this article is a preliminary step towards identifying and reporting the psychosocial chal- lenges of living with HIV and the impact of the group on individual members. The initial organization of the groups, the format, content, structure and practical considerations such as ws t and accessibility are described. 'Ihe results of pre and post test questionnaires examining '

isolation and group usefulness are also presented in this article.

INTRODUCTION

T h e complexity o f psychosocial stressors that surround children infected with HIV and their families continue to be defined and

Lori S. Wiener, PhD, is Coordinator, Pediatric HW Psychosocial Support Program. National Cancer Institute; Elizabeth DuPont Spencer, MSW, is Clinical Social Worker, Institute for Behavior and Health, Inc.; Robert Davidson, ACSW. is Senior Social Worker, National Institutes of Health; Cynthia Fair, MSW. MPH, is Clinical Social Worker, National Institutes of Health.

Social work with Groups, Vol. 16(3) 1993 55

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56 SOCIAL, WORK WITH GROUPS

better understood as the epidemic ends its eleventh year. HIV pre- sents unique social issues which now have been well documenkd. These issues include fear of disclosure of the diagnosis to relatives, friends, neighbors and employers; social stigma, ostracism, and death. Since a child with AIDS usually indicates a whole family as Wig at risk of infection (Wiener & Septimus), additional issues for the family include the loss of hopes and dreams of a future together as well as the potential for acute illness and/or loss of physical and mental abilities in multiple family members at the same time. Addi- tionally, all too frequently families lack the support of the very communities that traditionally have rallied around the care and support of children facing life-threatening illness (Pizzo, 1990).

Hospital social work staff, community based organizations, case managers, private practitioners, and others have worked diligently to provide the needed support for families faced with HIV in one or more family members. However, support from a natural support network-others faced with the same situations-is hindered by the fear of lack of confidentiality and the negative social consequences often associated with revealing an HIV diagnosis.

In December of 1986, the Pediatric Branch of the National Can- cer Institute (NCI) at the National Institutes of Health began incor- porating pediatric H N within the existing pediatric oncology pro- gram. The Pediatric Branch currently offers clinical trials to HN-infected children from three months to 18 years of age. There are approximately 300 children who live in 37 different states who have received treatment for their H N infection at NCI. A number of therapeutic modalities have been developed to provide support to HN-infected children, their siblings, parents, and extended family members at the NCI wiener, Moss, Davidson, Fair, in press). For example, a Telephone Network has been established to bridge the gap of wide geographic distances between families who are experi- encing similar events. Based on the successful experience with the Telephone Network the concept of a telephone group emerged,

BACKGROUND

The telephone was first used as a method of outreach in 1953 in London by the Samaritans for suicide prevention (Grumet, 1979).

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Since that time, telephone contact has been used in many ways by health care professionals. For example, crisis intervention (Hom- blow & Sloane 1980), outreach for physically disabled people (Evans et al., 1984), and ongoing psychotherapy (Shepard, 1987) have all been conducted via the telephone. In recent years the telephone has increasingly been used by social workers as a means of reaching isolated populations, or people with a rare condition or problem who would not otherwise have access to group therapy (Bertcher, 1990).

The helpfulness of group therapy has been established through both direct comparison for outcomes and through the prevalence of this form of treatment. Vinogradov and Yalom surveyed 32 studies of direct comparison between individual and group therapy for people who had interpersonal problems, and found equal or better outcomes for the group attendees than the people in individual therapy (1989). Group therapy promotes a specific goal of increasing interpersonal satisfaction by sharing mutually gratifying relationships. These rela- tionships can be initiated in the relatively safe environment of the group (Viogradov & ~a lom, 1989). Groups offer the benefits of mutual aid from others with the same life problems, promoting a feeling of universality and vicarious learning (Shulman, 1984).

Telephone groups have been used with several populations in- cluding elderly individuals with visual impairment (Evans & Jaure- guy, 1982), people with physical disabilities (Evans et al., 1984; Evans, Halar, & Smith, 1985). caregivers of people who are home- bound, as well as individuals who have multiple sclerosis and those who want information and counseling on safer .sex practices (Rounds, Galinsky, Stevens, 1991). Phone group participants and workers have reported that there are subtle differences from face-to- face groups. An increased sense of confidentiality often occurs. This is an essential component in providing clinical services to HIV-infected children and their family members who often refuse to attend face-to-face groups because of fears associated with dis- closure and loss of confidentiality.

METHOD

The NCI Pediatric Branch social work staff identified nine differ- ent populations who potentially could benefit from a telephone

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support group. These included HIV-infected girls, siblings of in- fected children, infected and non-infected mothers, infected and non-infected fathers, foster and adoptive mothers, and grandmoth- ers and grandfathers who were primary care-givers. Support groups that are run three times each week in the Pediatric Branch clinic are not separated by modes of acquisition. However, for the nine tele- phone support groups commonality in group members was main- tained initially because it was also felt that sensitive issues specific to a certain population (infected versus non-infected mothers for example) might not have been discussed had group membership been mixed. Groups for HN-infected boys were not conducted by phone initially because it was felt boys would not use this modality well. Instead, a project using a computer bulletin board to facilitate remote communication was initiated for this population (DuPont, 1991).

Three social workers and one social work intern were assigned to run the nine different groups. Each group comprised four to six members who expressed an interest in this type of group modality. The groups generally were run in the evenings and were arranged through AT&T Tel-Conferencing (Telephone conference calls). There was no cost to any group participant. Groups lasted four to six consecutive weeks with sessions lasting approximately one hour in duration.

For consistency, leaders followed a specific format for each group, although the groups were conducted as client-directed sup- port groups. The leader provided basic structure to the groups by opening the f i s t telephone group session with an explanation of the purpose of the group, then asking the members to introduce them- selves. In each subsequent group session the leader began by sum- marizing the prior group sessions, and then opening the group dis- cussion to the members. During the last group session, the members were invited to talk about their feelings about the group experience. Client-directed groups allowed participants to talk about whatever was most urgent at that time. Frequently a group focused on the concern or problem of one member, and all participants worked together to provide experience and resources. This occurred, for example, in the non-infected mother's group as one group member

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and her family chose to go public during the month the group was held, telling people in their community about the H N diagnosis.

In these client-directed groups identification, universality and normalization of feelings were key elements in the group experi- ence. Lieberman (1983) described the same process in his study of widows' groups. Support groups in general differ from therapy groups because they do not aim to ameliorate interpersonal or in- trapsychic difficulties, though this may occur as a secondary result of participating in the group (Zambelli and DeRosa, 1992). There- fore, there was relatively little confrontation, interpersonal explora- tion or process interpretation in these groups (Speigel et al., 1981).

A pre-test questionnaire which assessed demographic informa- tion, feelings of isolation and quality of social suppon was adminis- tered by telephone one week prior to the initial group session. One week following the last group session, a post-test questionnaire was administered by telephone. This questionnaire asked the same ques- tions about social support and feelings of isolation and also assessed the usefulness of the group.

THE SAMPLE

Forty group members participated in the study. The sample con- sisted of five HIV-infected girls and 21 female family members and 14 male family members. In six cases more than one family mem- ber participated in a telephone support group. Seventy-two percent of the identified 34 children lived with their biological family, 15% lived with the4 foster or adoptive parent(s), and 13% lived with extended family (grandparent, aunt, etc.)

The pm-test questionnaire revealed that the majority of respon- dents (59%) kept information about the child's HIV diagnosis re- stricted to family and friends while 38% of the respondents had gone "public," meaning that they have told people other than fami- ly and friends. Three percent of the respondents told "no one." Approximately half of the respondents (45%), felt that their support system was limited, that is to say they felt that "support is not always available." Thirty-seven percent of the respondents felt that their support system was good, 15% of the respondents felt that

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60 SOCIAL WORK WITH GROUPS

their support system was excellent. Only one respondent (3%) felt that his support system was poor.

EXAMPLES OF THEMES AND CONTENT

Each telephone group session was tape recorded and transcribed verbatim. Although an attempt was made to develop a series of qualitative topic codes to facilitate content analysis of the data based on the participants experiences in coping with HIV, each group reflected different themes. Themes were identified by re- viewing transcripts of the group sessions, and are reported here in general terms. The grandfathers' group, for example, focused on the needs of these individuals for support and their relationships to their grandchild and their families. They were also able to provide each other with praise, a feeling of hope, and renewed faith and accep- tance. Similarly, the grandmothers' group revolved around themes of multiple demands, task overload, and the numerous losses they had each already experienced.

In contrast, the non-HIV infected fathers' group involved themes of public disclosure versus secrecy and raising children in a climate of constant lies and isolation; their children's courage and identifi- cation with each other's feelings of hope, guilt, sadness and need for supportive relationships. The non-infected mothers' group simi- larly stressed the pro's and con's of going public with the HIV diagnosis, while the HN infected fathers' group revolved around themes similar to the non-infected fathers' and mothers', but stressed the central theme of guilty which all of the men felt.

In contrast, in the foster and adoptive mothers' group the unique- ness of being a foster parent (four of the women had a child of a different racial background than themselves), the reactions of their family and friends to taking in an HN-infected child, and living with the threat of death were the predominant themes. For siblings, themes in the group included the need to find someone whom they. could talk to about the diagnosis, feeling responsible, and fears associated with their own potential destiny. The situation of a child who will ultimately lose one or both parents and their sibling(s) to AIDS is staggering even to imagine. But the siblings in this group

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talked openly about these issues, especially the underlying fear of being leftealone as the following quote so vividly demonstrates:

I have a picture taken when my sister was five months old, and it was mother's day and it was me, my mom, and my sister. I think about it all the time that it's going to be only me left, in the end. It feels really weird.

Because of space limitations, only two the groups are described in this paper, accompanied by examples of dialogue that occurred in these groups.

HIWnfected Girls

This group consisted of five HIV-infected girls ranging in age from 9 to 14. The girls were each from different states and had not p~vious- ly met. Three were HIV-infected through birth. The other two acquired their disease through transfusion of contaminated blood products for a secondaty medical condition. It was evident from the onset of the group that there was an immediate and strong bond among the girls. They shared secrets they had never told anyone else, frightening and funny dmuns, and details about how they perceived specific medical procedm. They cried together when the content was based on their feelings about dying. The bonding was most evident during the last group meeting when they decided to sing songs together and to make plans to meet one day. Several themes emerged over and over in this group. In particular, two topics emerged that could not be easily shared , with others who had not experienced them first hand. The first was learning about the diagnosis:

When I first found out it's-like hiding under a blanket and you can't tell anyone because it's just this dark little spot and you're all alone. You just keep letting people in and one time you think that someone is just goirig to crawl out and tell everyone else not to go in.

Telling others and the fear of being identified also was a topic of repeated discussion:

If I tell my best friend she could tell anybody and then my whole reputation is mined and so is my family's.

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62 SOCIAL WORK WlTH GROUPS

Fear of separation was a predominant issue throughout the group sessions. It was evident in most of the dreams described by the girls. The most tearful interchanges occurred at the times when the girls shared their fears associated with progressive illness and separation from their parent (s).

The telephone group appeared to provide the girls with a new feeling of acceptance and belonging. The following remarks from the last group session further illustrate this point:

This group has actually changed my life. . . . I can talk with people here and not feel like they will tease me . . . I love this. It is fun 'cause it is the very fmt time I have gotten to tell somebody outside my family about my secret. And I feel better about it because I know what they are going through.

HN-Infected Mothers

Two groups of HIV-infected mothers were conducted. The first group consisted of three women. The second group consisted of five women. Each woman had at least one infected child. Several women had already lost a partner to AIDS. Group members were scattered across the United States, came from varied racial and economic backgrounds, and were in different stages of their own illness. Despite differences, members formed deep and lasting rela- tionships. The themes that immediately and consistently emerged in these groups included coming to terms with the past, hope, personal growth, faith, concerns over changes in one's own health status and living with the threat of death. The group members were able to talk openly about subjects some claimed never to have been able to come to terms with before, especially regarding their past behavior.

My mother does not know me straight. As soon as I became an adult, I became an addict. I was like a child for 12 years. So I really want her to come and see how much I've accomplished, not what I am losing.

Some group members did not feel quite so courageous about talking openly with others, even their family members, about their H N

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diagnosis. The response was one of understanding and support from other group members.

I'm trying to protect my family. I live in a small town. I'm afraid to let it (the HIV diagnosis) be known right now. I pray that I can one day stand up and be bold and speak about me and my daughter.

(In mponse) That takes time. Those things will come slowly. . . . it is a process, a growing process, a process of empowerment and faith, and love and courage and believing in miracles and believing in everything that you took for granted before.

Inner strength derived from spiritual and existential faith was much stronger with the HIV-infected women than it was in any of the other telephonesupport groups. One theme that was unique to this group and emerged along with the discussion of the power of life was fears associated with changes in one's own health. It was revis- ited each session depending on how the group members felt physi- cally during the preceding week. These women talked honestly about what it was like to live with the threat of death.

. . . too scared to close your eyes. if you go to sleep and wake up your baby might be gone . . . when you, make love to your husband, you're not listening to his breathing, you're listening for yow child in the next room. It's temfying. Absolutely terrifying. But that's life, at least our life.

As these statements illustrate, these women were ready and eager to talk about issues that were too painful even to consider previously. Their bond was strong and intense, though the women were from widely different racial, ethnic and cultural backgrounds. For each, the group was part of the "process" evolving considerable personal growth and suppoa.

Hope. These phone calls are hope. I look forward to it. When that phone rings and I answer it, and they say 'This is your conference call,' I'm happy. I'm like O.K., well, here come my girls. I get to talk to my buddies.

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FINDINGS

The post-test questionnaires supported the group leaders' im- pression that the groups were helpful. Eighty-five percent of the members reported that they felt better about themselves in the time since starting the group. Eighty-three percent of the members felt better about their ability to cope, and 80% felt better about their ability to handle their child's illness. Following the group experi- ence, the participants felt significantly less alone with their prob- lems (p = 0.02). There was also a significant diKerence (p = 0.03) in the response to the statement, "People try to be helpful but nothing they say makes much difference." Six months following the completion of the group, the participants were again asked how they felt about the group experience. They continued to feel that the group had been a positive experience (see Table 1). Seventy five percent of the respondents would have liked the group to continue and 97% would have liked to be involved in another telephone support group.

There were some interesting differences between the pre- and post-test responses of the men and women who participated in the groups. Following the group there was a tendency for men to feel they had good support from people they did not know well, that

TABLE 1. Sense of Self Ms~ondents Reoorlina "Usuallv or Alwavs True"

One Week Six Months Following Group Following Group

I feel better about myself since starting this group. 85%

I feel better about my ability to cope since starling this group. 83%

I feel better about my ability to handle my child's problems since starting this group.

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they were able to answer questions from family and friends regard- ing their child's illness, and that they did not prefer to keep their child's illness a secret to the same degree that they had prior to the group experience. For women, no significant changes in these areas were found. However, following the group experience, they felt significantly less alone with their problems and more understood by others (Table 2).

PRACTICAL CONSIDERATIONS

For those interested in implementing telephone support groups, four areas require practical consideration: (1) group composition; (2) length of group; (3) call waiting; and (4) noisy backgrounds.

TABLE 2. Attitudes tor Men and Women Prior to and Following Group Participation

Prior Following

MEN

I have had good support from people I don't know well 44%

I am able to answer questions from family and friends re my child's illness, 44%

I prefer to keep my child's illness a secret 67%

WOMEN

I don't fee that anyone understands what I'm going through 68% 22% p = 0.005

I k e l all alone with my problems 54% 35% p = 0.09

People try to be helpful but nothing they say makes much difference 58% 27% p = 0.02

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66 SOCIAL WORK WlTH GROUPS

Group Composition and Length of Group

To i n c ~ a s e feelings of commonality and to decrease a sense of isolation, telephone group composition should be restricted, if pos- sible, to members of the same gender at similar stages of illness. Optimal size of group membership depends on several factors in- cluding: (a) how verbal the group members are; (b) how long the group sessions will last and (c) the skill level and comfort of the group leader. In this study, groups of four to six members worked well when the leader allowed each participant the opportunity to comment on the different themes that emerged. However, leaders with little or no previous group experience might want to limit the number of members to four.

The post-test questionnaires revealed no significant differences regarding how helpful the group was between-groups of four, five, or six members, groups that ran for four or six weeks, or for the groups that ran for one hour versus the groups that ran for one hour and 15 minutes. The transcripts of the sessions that ran for over one hour and 15 minutes were less organized than those that ran for one hour to one hour and 15 minutes. Because of the intensity of the group content the groups that ran for over one hour and 15 minutes were also described as more emotionally and physically exhausting for the leaders. Sessions that ran for four consecutive weeks were preferable for both new group members and group leaders, as a "one month commitment" appeared less overwhelming than a longer term commitment.

It also appeared that there was less of a commitment to the group when members had previously known each other well. This was especially true for the uninfected mothers group, since they all knew each other from hemophilia society group meetings. Meeting others via the telephone for the first time allowed a greater sense of confidentiality and an abiity to share one's inner thoughts, feelings and fears more easily. Interestingly, in all nine groups that were conducted for thii study and with each group that has been run since this study was completed, members chose to share their names and telephone numbers during the last group session. In response to this express need for closeness the leaders asked the group members to share with the group during the last group session a poem, story or

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prayer that has been a comfort to them. The leader remains an active participant by sharing a poem as well. The leaders then collected photographs from the group participants of themselves and of their HIV-infected child(ren). The poems and photographs were photo-

. copied and distributed to a l l group members shortly following the last group session.

Call Waiting and Outside Noise Distractions

Many telephones now have a call waiting option where one can put a call on "hold" and take another call. When this happened during a telephone support group, the participant missed part of the session. It was distressing to the other group members who would ask questions or the opinion of a member, only to find that the person was not currently on the line. Therefore, the group leader encouraged the group members to restrict taking call waiting calls to when they were expecting an emergency call, and to inform the group prior to getting off the line as well as when they return to the group.

Many families do not have the luxury of living space which would allow the group member to have a quiet room of his or her own in order to speak privately and without disruption. Therefore, each group was planned for the time of day when the family mem- ber would have the most time to hirn~herself. This took considerable coordination, especially when the group members lived in different time zones. Most people were able to work out some support for the hour they were on the phone when they had enough time in advance to plan for the group.

cost

Perhaps the most important practical consideration was cost. In general, AT&T currently charges 49 cents for one minute of confer- ence time per person regardless of location, or $29.40 per hour. There is also a $3.50 set-up charge per person that is applied in most situations.

Federal workers may arrange groups through the Federal Tele- phone System (mS). Cost to the government through FTS is 15

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cents per minute with a $5.00 set-up charge per person. Conference calling can be accomplished in one of three ways: (1) A demand conference-the operator sets up the call and then accesses each participant (or the group leader can call each participant for a sub- stantial savings); (2) A resewed conference-the operator sets up the conference and accesses each participant at a prearranged time, or (3) A meet-me conference-each participant may call a "700" num- ber at an agreed-upon time, accessing the conference individually. For the HIV support groups, reserved conference calls worked best and each group participant knew the time, date, and confiat ion number for each group session well in advance.

DISCUSSION

These telephone support groups were a creative and therapeutic way to help HIV-infected children and their family members cope with the impact this disease had on their lives. The groups were especially effective for this population, since children at NCI trav- eled from diverse geographic locations to receive treatment for their disease. The groups provided a sense of confidentiality not afforded in a face-to-face group. Interactions in the groups contained a con- siderable amount of selfdisclosure and sharing of mutual fears and concerns. The groups helped create a climate of acceptance and support for individuals who were often isolated because of the stigma associated with this disease and the lack of adequate support networks in their communities. The post-test questionnaire repeated six months after the last group session supported the impression that the group helped the members feel better about themselves, about their ability to cope and about their ability to handle their child's problems. This model could clearly be adapted for children and their family members who suffer other medical illnesses, especially those who remain socially isolated, such as those on dialysis.

The leaders of a telephone support group must be particularly attentive to group dynamics, since there are no visual cues or ways to assess body language, as in a face-to-face group. Voice tone and inflection, silences and withdrawing from conversation (by actually putting the phone down for a period of time), are cues to which the

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leader must be sensitive (Rounds, Gatinsky, Stevens, 1991). It is important for the leader to remain an active participant, especially during times when a member appears to be withdrawing. Re-engag- ing members who are withdrawing is facilitated by acknowledging that the content being discussed appears difficult, and asking each group member to share with the group what is most difficult for

~ ~

them at that moment. , Additionally, as the issues of death and loss inevitably provoke

countertransference responses, a group leader must examine his or her own reactions. The dying patient specifically confronts the ther- apist with guilt, often reactivates past losses, and serves as a re- minder of one's own mortality (Norton, 1963). Common counter- transference responses such'as denial, protectiveness, reassurance, false optimism or intellectualization can interfere markedly with one3 ability to respond appropriately to the groups' needs. For a group leader to communicate that it is safe to walk the path of living with eventual death, he or she must feel safe enough to make the journey as well (Kaplow, 1992).

Living with life-threatening illness and learning new ways to cope with the threat of eventual death permeated each of the groups. In each group the participants struggled with reordering their priori- ties and shared their sense of commitment to enjoying the time remaining 'to them. Most important, the members gave each other hope, courage, strength, compassion and support. The leaders were permanently moved by their resilience and wisdom. By the end of each session, both coup members and group leaders recognized death would come, but that life could and would go on. The follow- ing observation taken from the last fosterladoptive mothers' group and which is based on one woman's spiritual faith, eloquently sum- marized this perspective:

I just look ahead a lot. I look ahead not to the point where things get bad, but beyond that. And I know that it's not always going to be like this. There's going to be a time when all the death is behind us, and al l the pain and all the suffering. That to me is the biggest comfort. And it's like no matter what kind of hell goes on today, I just know that one day, God says He'll wipe away all of our tears, and there'll be no more pain

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70 SOCIAL WORK WlTH GROUPS

and no more sorrow. And I just really hold onto that and I just look ahead to that day and imagine, if I can, what it will be like. There will be a day where there is no more rejection for us. There will just be a day. And I live for that day.

REFERENCES

Bertcher, H., ed. The Tell a Group Hotline Newsletter. DuPonl E. (1991) Support Through Computer Networking: Groups for Boys with

HIV Infection. Resentation at the Third International Conference on Social Work and AIDS. New Orleans. Louisiana.

Evans, R.L. et al. (1984). Group Treatment of Physically Disabled Adults by Telephone. Social Work in Health Care. 9(3), 77-84.

Evans, R.L., Halar, E.M., & Smith, K.M.(1985). Cognitive Therapy to Achieve Personal Goals: Results of Telephone Group Counseling with Disabled Adults. Archives of Physical Medicine & Rehabilitation. 66,693-696.

Evans. R.L., & laureguy, B.M. (1982). Phone Therapy Outreach for B l i d Elder- ly. The Gerontologist. 22(1), 32-35.

Grumet, G.W. (1979). Telephone Therapy: A Review and Case Report American Journal of Orlhopsychiatry. 49(4), 574-584.

Hornblow, A.R. and H.R. Sloane. (1980). Evaluating the Effectiveness of a Tele- phone Counselling Service. British Journal of Psychiatry. 137.337-338.

Kaplow, L. (1992). P i d i g Common Ground: Pacilitatlng a Therapeutic Group for Diverse Parents of Young, Disturbed Chil&en. Zero to Three, February, 22-26.

Lieberman, M. (1983). Comparative Analyses of Change Mechanisms in Groups. In R.Dies & K. MacKenzie (Eds.) Monograph I: Advances in Group Psycho- therapy: Integrating Research and Practice @p. 191-208). Madison, Interna- tional Universities Press.

Norton, T. (1963).Treatment of a Dyiig Patient. The Psychoanalytic Study of the Child,18,541-560.

Pizzo, P. (1990). Pediatric AIDS: Problems Within Problems. Journal of Infec- tious Diseases, 161,316-325.

Rounds, K.A., M.J. Galinsky, L.S., Stevens. (1991). L i g Persons with AIDS in Rural Communities: The Telephone Support Group. Social Work, 36(1), 13-18.

Shepard, P. (1987). Telephone Therapy: An Alternative to Isolation. Clinical Social Work Journal. 15J.56-65.

Shulman, L. The Skills of Helping Individuals and Croups. (1984). Itasca, Jlhois: P.E. Peacock.

Spiegel, D., Bloom, J. & Yalom, I. (1981). Group Support for Patients with Metastatic Cancer. Arch Gen Psychiatry, 38,527-533.

Viogradov. S. and I.D. Yalom. (1989). A Concise Guide to Group Psychotherapy. Washington, D.C.: American Psychiatric Ress, Inc. 1989.

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Wiener el al. 71

W~ener, L & Kaplan, M. (1988). Psychosocial Ramifications for Parents of Pediat- r ic AIDS Patients. IV International Conference on AIDS, Stockholm, Sweden

Wiener, L. & Septimus A. (1990). Psychosocial Consideration for the Child and the Family. In P. Pizw, C. Wilfert (Eds), Pediatric AIDS @p 577-5941. Balti- more: W~lliams & wlkins.

Zambelli, GC & DeRosa AP (1992). Bereavement Support Groups for School- Age Children: Theory, Intervention, and Case Example. American Journal of

. Ortltopsychiatry, 62(4). 484-493.

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