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

`Yesterday I started to look at why pain management using a CBT approach can work well in groups.  As I mentioned, it’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  Yesterday I looked at how a group approach can offer participants a sense of optimism.  Today I’m looking at inclusion (sense of commonality), and group-based learning.

One of the most striking features of having an invisible health problem is that many people can be walking around in our communities with their pain without anyone being any the wiser.  The sense of isolation experienced by some of the participants in the pain management programme I work on is astonishing.  It’s as if they are living in a bubble that makes interacting with other people profoundly difficult.  Being in a group setting with other people experiencing similar problems offers some really important things:

  1. a sense of belonging, to recognise that chronic pain is experienced by other people who struggle with the same issues
  2. a sense of normalising – recognising that some of the experiences are not strange or a sign of some unique failing on the person’s part, but are simply part of having chronic pain
  3. the opportunity to learn from others who may have faced and coped well with very similar situations and arrived at helpful solutions
  4. shifting the focus off the individual and offering them the opportunity to help others.  This can be an empowering situation for individuals who can otherwise feel helpless and hopeless.

The way the therapist facilitates group members to develop the sense of safety needed to share experiences, and confidence to offer opinions (especially opinions and doubts that contradict the ‘proper’ way to manage) is crucial to the success of the experience.

I begin the group programme with a brief outline of the purpose, housekeeping, and then very briefly ask particpants to share a little about themselves.  At the very beginning of a three-week programme it’s unnecessary, I think, to start with ‘icebreakers’ and I find many people simply hate them! So it’s a very simple ‘tell me a little about yourself and why you’ve come to the programme’.  Later on in the day I use the whiteboard to brainstorm all the possible topics that people might want to have the programme cover – I use a very open approach to do this, allowing the more vocal participants to start this process off.  Once a few topics are on the board, I’ll then start to prompt ‘people who haven’t had a chance to speak’, and I also allow some periods of silence because some participants need that time to process thoughts into words.

It’s once topics are on the board I notice that participants begin to warm up to each other and start to share the ‘back story’ of why some of the topics they’ve suggested are important.  Allowing this to happen without too much direction helps set the scene for people to see that the group includes people ‘just like me’, and I find the less vocal people start to show nonverbal participation.  Sometimes at this point it can be helpful to break off into pairs to share one another’s journey to coming to the programme – having to speak to only one person can help to make speaking and feeling included easier.

At this point the therapist can facilitate slightly deeper sharing – saying something like this:

Therapist: ‘Now that we’ve spent some time hearing about what’s brought people to the programme, and what they want to learn, we can see that although each person is unique, there are some similarities that you all share.  What do people think or feel about what they’ve heard?’

Tom: ‘At last there are other people who know that I’m in pain when I say I’m in pain!’

Alison: ‘It’s really strange because I’m usually the only one in pain and feeling like I really need to stand up or jiggle, and here are a whole group of people doing the same!’

Group laughs then silence

Therapist: ‘What about for others?’

Tony: ‘I thought everyone would be ACC whiners, but you’re not.  Is anyone else on ACC here?’

Andrea: ‘Yes I am, and I’m worried that ACC is going to kick me off compensation straight after the programme, and they’ve made me come here and I can’t work like this.’

Therapist: ‘It’s really great that you’ve talked about this Andrea, because a lot of people do worry about what is going to happen after the programme.  About half of this group are on ACC compensation, and we’ll talk about how to work with your case manager and what to plan for after the programme in several sessions.  It’s also a really important point you’ve raised about ACC making you come along.  Does anyone else feel like they’ve been made to come to the programme by someone else?’

Alison: ‘Well, I thought so at first because my case manager suggested I come to Pain Management, but when you did the screening you explained that I could decide whether the programme was for me or not, so I’m feeling OK about it now.’

Therapist: ‘Thanks for saying that Alison.  You’re right, coming to the programme is absolutely your choice, and it’s important you decide to be part of it yourself, and not for anyone else.  Not a partner, or a child, a doctor or even ACC can make you come along.  If you’re here because you think someone else made you attend, I can reassure you that if you decide at the end of today that this is not the right thing for you, we will communicate this with your case manager and there will be no penalty.’

This is an important ‘doubt’ that many people can have when asked to attend a pain management programme, as many people with chronic pain have some sort of relationship with a compensation agency.  We have a policy that people must be ‘ready’ to attend a programme for themselves, because we’ve found that although it’s possible to include people who feel coerced to attend and the group process can work with this, it makes progress very difficult.  Self management is that – self management.  It’s a choice, and people do need to be ready to pursue it.

Even after selecting people carefully for inclusion, participants can continue to feel worried about the consequences of completing a programme, and this is an issue to discuss openly.  We start doing this by a process called ‘fears in a box’, where after about three days, participants are offered the opportunity to write down their concerns or doubts about the programme, and place these thoughts in a box.  The team members review the written questions and at the end of that day, directly discuss these issues with the group.  Many group members say they feel relieved because they thought they were ‘the only ones’ to have the doubts, but typically it’s something many of them feel.  Offering participants a chance to anonymously air their worries helps the whole group feel more comfortable sharing their unique worries, allowing the therapist/facilitator to work through the issues to resolve them.


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