I’m going to jump ahead of myself in this discussion of pain management in groups, using a CBT approach, and cut to a description of therapist factors that can influence how well a group programme works. I should add at this stage, that I’m basing much of what I write on my own experience over …ermmm… a few years… but also from an extremely helpful book ‘Cognitive behavioral therapy in groups’ by Bieling, McCabe and Antony. It’s published byThe Guilford Press, New York, 2006, and is a hefty 452 pages long. It’s a great book —- but it doesn’t have anything about chronic pain management, so I’m working on describing how the factors that are discussed in this book can apply in chronic pain management.
OK, so while I’ve been looking at group process and the benefits of conducting pain management in a group setting, one of the critical ingredients has to be the clinician or clinical team involved in the programme. Our team has six clinicians, and something we’ve worked on very hard is having a common model and developing consistent responses to various issues that different participants bring into our programme. It only takes one clinician to say something ‘different’ for participants to become confused or worse, defensive and at times work to ‘split’ a team. Pain management often runs contrary to ‘common sense’ – chronic pain management doesn’t follow the rules of acute pain, so if someone is fearful of moving and one clinician reinforces this, however well-meaning, it can stall reconceptualisation and stop progress.
Group programmes using a CBT approach need facilitators who are not only confident in themselves (they’re ‘on show’!), but also be both confident in applying CBT in a one-to-one setting, and also work well with group facilitation (ie know how groups function). They also need to be well-trained in chronic pain management. Transferring generic CBT skills into chronic pain is a challenge – but transferring generic CBT skills into a group setting is impossible without some mentoring and opportunity to observe. I’m glad to see that this point is made very strongly in the book I referenced above!
In fact, that book recommends the following:
- Didactic coursework/training in CBT models and techniques
- Direct (hour for hour) supervision on multiple individual cases of CBT
- Observational participation in a CBT group led by another therapist
- Taking on the role of a co-leader
Well I can’t quite see that being given to new people joining many public hospitals in New Zealand!
Therapists need to have some specific facilitation ‘styles’ that work for group facilitation:
- They need to model ‘active participation’ – in other words, really be involved in the processes of the group
- They need to be tolerant and open to individual differences, there is no ‘correct’ way of responding, just varing consequences im both short and long term
- Use collaboration and Socratic dialogue to guide participants through the process of discovery. ‘Teaching’ doesn’t work well, ‘discovering’ works better, ‘experiencing’ works best.
- Communicate that ‘we’ are all prone to the same thinking patterns and responses – never ever giving the impression that they ‘have it all together’ or that they wouldn’t be vulnerable to the same thoughts, feelings and behaviours that the participants have. After all chronic pain is not choosy – it could be you, and it is me, that can have chronic pain!
I’ve not often had the opportunity to work with a cotherapist, but when I have, it’s been wonderful! A point made in many manuals for CBT in a group setting is that two therapists are preferable. One can do the majority of the facilitation, while the second can be observing, noticing, listening and providing back-up when the primary therapist runs dry. If two therapists are going to work together, though, they need to have some idea of who is doing what, and what the potential issues might be. AND, more importantly, they need to debrief afterwards to see what they both saw during the session.
I’ve found that it’s great to have an email or some other system to share observations and notes from each session – especially when different therapists provide input over different sessions during the day. And as the therapists hand over to the next person, a brief exchange of ‘what’s going on in the group’ makes a huge difference. For example, if one person has had a flare-up and is having trouble, it’s good to know what has already been said or suggested so either the same approach is used, or the person isn’t faced with the same questions or process from the next therapist!
As the group develops, the participants can take on some of this ongoing monitoring and reminding process, but especially during the initial stages, it’s vital that therapists keep their eyes and ears open and share what they observe.
To help with learning, I’ve attended training on group facilitation (Zenergy in New Zealand is one provider I particularly respect), and I’ve also participated in personal growth courses, especially those using experiential learning methods. I think these skills also help when facilitating group-based CBT for pain management. One book I’ve found especially helpful is Open to Outcome which gives you five questions you can use to debrief from any experiential activity. And of course, Thiagi has a huge resource of both brief and more complex experiential activities that you can use in groups.