Pain management in groups using a CBT approach – Why do it?

I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion.

I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people might think…).  I know I’m not alone in feeling that when I’m with people I don’t know well, I am not exactly open to pouring out my woes and being emotional. It can take quite a while to feel comfortable about expressing feelings in a group setting – but at the same time there is something comforting in knowing that if I’m feeling wobbly there are probably a few other people also feeling the same way, so we may all reach for the tissues at the same time!

Processing emotional content in a group setting can be both an amazing experience and at the same time an opportunity to feel really weird.  It all depends on how the facilitator or therapist responds.  Through exposing emotional content, we have greater access to automatic thoughts, assumptions, beliefs and behaviours that are often otherwise well hidden underneath our protective cognitions.  It’s at times when we feel more emotionally vulnerable that we have access to underlying ‘rules of living’ that we may otherwise be completely oblivious to.

What should a facilitator take notice of?

– times when a participant appears disengaged, perhaps doodling, or closing the eyes, maybe rocking on the chair or fiddling with a pen.

What could a facilitator do? To illustrate one way of drawing out the emotional response and opening up an opportunity to talk about what is happening here and now, the therapist could say:

Therapist: ‘before we go on, I just want to check in with the group.  Tony I can see you’re looking a bit distracted, what’s going on for you right now?’

Tony: ‘Oh nothing’

Therapist: ‘Oh.  How does what we were talking about fit for you?’

Tony: ‘Well, I’m just thinking why do I have to be here? I mean, I don’t think my pain is really chronic, and I know I can have another injection if only I talk to the doctor again, so do I really have to do all this psychological stuff anyway?’

Therapist: ‘Does anyone else feel like it’s going to be a really difficult process to learn self management, and maybe there is an easier way other than looking at thoughts and emotions and things?’

Andrea: ‘Well, yeah.  I mean, some of the doctors have said that I can just increase my medications and then maybe my pain will go down and I’ll be doing more, but I just can’t handle the side effects any more.  Those side effects can be worse than having the pain, I think.’

Therapist: ‘Does anyone else feel like it might be easier to just carry on with a medical approach and not look at other things?’

Tessa: ‘I tried that for years, but in the end I still have my pain and my emotions go  up and down every time someone suggests another medication – but I’m still here because I am so fed up with that rollercoaster, and I want to take control again.’

Therapist: ‘ Tony, what is it like for you to hear that other people feel in two minds about doing this self management approach, and there are some appealing things about using medications, but also some not-so-good effects?’

Tony: ‘Well I guess it makes me feel more normal, after all I’ve been on that emotional rollercoaster for a long time, and I really hate the side effects from medications too.  And the doctor said that he wasn’t very keen to give me any more injections.’

This approach can feel risky if you’re not used to facilitating – it’s allowing people the space to feel ambivalent and to process that anxiety but also to recognise that others in the group have also had similar experiences and offer either the same insight (I’ve been here before…) or a new insight (She’s handling it by being open-minded) that can reassure the person.  Provided that the facilitator can trust the group that there will be someone else who has moved through this same thought and emotion before, and go with the flow (roll with resistance), it’s possible to allow people to air their worries or emotions and still be able to move towards the goal of sharing and normalising many of the experiences the group shares.

Group cohesion is that sense that the group are ‘bonded’. There has been much written about the stages of development within a group – the ‘forming, norming, storming etc’  stages amongst others.  What happens is that over time a group may move to the point where it’s OK to disagree with each other, to challenge each other and to risk being ‘real’ with each other.  This can happen quite quickly, but I find that groups often get to the ‘I feel comfortable with this group’ stage (ie they all ‘get along’) but may get stuck and don’t move to the ‘it’s OK to be honest and real and disagree with each other’ stage.  It’s only when groups move to this deeper level of cohesion, IMHO, that they start to ‘work’ each other.

The therapist or facilitator can encourage this deeper relationship and here are several strategies that can also help:

  1. Choosing a group that has similar characteristics – eg stage of change or readiness to adopt self management, maybe diagnosis or pain site, perhaps compensation status or job status
  2. Ensuring confidentiality and creating the group norms
  3. Ensuring a climate of acceptance, empathy and promoting sharing of information
  4. Connecting two or more participants experiences
  5. Responding to group process as it happens

More about this last one tomorrow. Group process is all about the things I’ve raised over the last couple of days – disclosure, optimism, inclusion, group learning, shifting from self to others, and managing both emotional processing and group cohesion.

I’ll review these tomorrow and add in some specific strategies that can be helpful to elicit each one.


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