This week I’m looking a working effectively with groups for pain management using a CBT approach. Someone said recently ‘why should six clinicians be tied up for three weeks with only six patients? there are other people who need pain management too’ – and over the past ten years I’ve seen numerous attempts to move from the group approach to individualised therapy, so some time reviewing why groups are a useful way to help people develop pain management skills might not be amiss!
Using a group approach was typical for pain management in the earlier days, say around the mid-1980’s and earlier. It’s a convenient way to bring the specialised skills of an interdisciplinary team to people with pain, and especially within the setting often used in the beginning of CBT for chronic pain, which was an in-patient or residential setting.
Now things have changed with an increase in individual programmes, but still the majority of research is carried out on the outcomes of people attending group programmes (eg Edelman, Bell & Kidman, 1999; Thorn & Kuhajda, 2004 – this is a list that could go on!).
Why use a group?
Groups provide two main aspects that individualised therapy doesn’t, and these aspects are especially important for people with chronic pain. The first is the opportunity for the group to broaden the range of possible concerns and issues that can be discussed. Instead of drawing only on the issues that one individual chooses to raise, group members will bring many different situations, both similar to and different from, the ones that another group member may raise. This means many more opportunities for a person to learn how to apply cognitive behavioural strategies across different settings. Participants in a group setting often express how alone they have felt in coping with their pain problem and how helpful it is to find a group of people who have similar concerns.
The second is the opportunity for group members to develop and demonstrate using CBT with each other. Group members become, over time, much more able to challenge each other very strongly over issues common to them all, than a group facilitator. The multiple perspectives that individuals bring to viewing situations is very helpful when learning to challenge an assumption or belief, and the group setting provides a safer setting for developing the skills to challenge themselves.
Several other aspects support a group approach – operant conditioning occurs as group norms begin to shape behaviour. The group can begin to initiate ‘well’ behaviour, and support each other with this. (yes, it can go the other way – we’ll discuss this too!). Effective communication, a skill many people with chronic pain have not developed, especially with respect to communicating about their pain, is used during a programme. Observing others succeed or not, and the effective analysis of ‘what went well, what would you do differently’ is another aspect that is strengthened in a group setting, particularly as alternative options for ‘doing it differently’ can be suggested.
What is the difference between CBT in a group setting and CBT through a group?
I’m sure we’ve all spent time in groups where the discussion is rather stilted, directed to the ‘leader’ or facilitator, and members rarely, if ever, talk to each other. ( I can think of several staff meetings like this!) If a CBT approach is to work well in a group, it’s not just about a facilitator using CBT with each individual in turn – that’s just CBT in a group setting. To me it’s not nearly as effective as working through the group process using a CBT approach. The differences appear subtle when I’m writing them, but never FEEL subtle when a group is actively processing!
It’s the way the facilitator encourages group participants to start the CBT process with each other that makes or breaks the group as an active component of a CBT approach. I’m going to firstly discuss the group process within a CBT framework, and draw on Bieling, McCabe & Antony (2006) to do so. Today’s theme is ‘Optimism’.
Optimism. Believing that treatment will help, and feeling positive towards the outcome is an aspect of group process that is strongly influenced by the group and the facilitator. Facilitators can help group members encourage each other through modelling how they can do this.
Therapist: ‘Let’s see how you’ve planned to use activity regulation over the weekend, and let the group know what you think might get in the way of it’
Tony: ‘I’m going to work in my garden, but I’ve decided to use my phone to ring an alarm after 30 minutes so I stop before I overdo it. Then I’ll go and stretch and get a drink of water before I get back into it.’
Therapist: ‘What’s going to be the biggest challenge to doing this on Saturday.’
Tony: ‘Probably my wife coming out to see how far I’ve got, and I’ll feel guilty that I haven’t done it all.’
Therapist: ‘Anyone else in the group have a similar worry?’
Andrea: ‘Yes, that’s me. I’m sure that my husband will come out and take over whatever I’m doing and then I’ll feel I have to go on. What I’ve decided to do is one part of the house that he never cleans – the toilet!’
Therapist: ‘That’s one way around it! Justine, what do you think Tony could do?’
Justine: ‘I decided last week to tell my partner and my kids that this is my project and I want to do it myself. I did feel worried about this but I picked up that I was listening to a ‘should’ statement, and so I asked myself where it was written that I ‘had’ to get it all finished and that everyone else ‘had’ to be happy with it!’
Therapist: ‘And what happened?’
Justine: ‘The family left me alone until I went in for a coffee break, and then they said I’d done more than they expected! So Tony could do the same thing, and maybe remind himself that doing something is better than doing nothing at all’
Therapist: ‘What do others in the group think about this suggestion?’
Therapist: ‘Justine, do you think you can say this directly to Tony?’
Justine: ‘Tony, do you think you can remind yourself that you’re doing more than you usually do, and breaking it up like this means you’ll be able to carry on longer in the day?’
Tony: ‘Yes, and I remember you, Graham, were saying the same thing about feeling guilty. What do you think about this?’
Graham: ‘I do feel guilty when my family have to take over for me, but I liked what Justine had to say about doing something and it being more than nothing. I could remind myself about this when I start worrying about what my family are going to say.’
Several things helped in this exchange – the therapist drew on the group’s common experiences, asked for specific responses (and more than one), then helped that person direct the comments to a group member rather than to the facilitator.
More on this tomorrow! Remember you can subscribe using the RSS feed link above, or you can bookmark and come on back tomorrow! Comments and feedback welcome, just remember that comments are visible to all. To contact me more privately, use the ‘About’ page and send me a message direct.
Bieling, McCabe & Antony, (2006). Cognitive behavioural therapy in groups. The Guilford Press: New York.
Edelman, Sarah; Bell, David R; Kidman, Antony D (1999). Group CBT Versus Supportive Therapy With Patients Who Have Primary Breast Cancer, Journal of Cognitive Psychotherapy.
THORN Beverly E; KUHAJDA Melissa C, (2006). Group cognitive therapy for chronic pain, Journal of clinical psychology , 62(11), 1355-1366.