Efficiency & pain management

I can’t remember a time when people working in health were told ‘Go and spend as much as you like to help people get well’ – in fact, in over 20 years I can only recall being told ‘there is less money in the kitty, we need to look for efficiencies, tighten your belts’!

So it’s no surprise to me that once again, no matter where you look in the world, health professionals are being told to look at ways to be more efficient.   I don’t have a problem with this – if I’m a patient I want to know I can be treated quickly and effectively so I can get back to being a person and not a patient.  What I do have a problem with is when, in the urgency to save money, problems in health care are given a quick fix solution without taking a look at the systems in which the services are being delivered.

With a chronic health problem, the main problem is that patients don’t get cured.  This means that once a person has been seen for treatment, it’s highly likely they’ll return – so along with new referrals to a service, there is a steady stream of people being re-referred, and what isn’t entirely clear is why they might need to be seen again.

Let’s take a look at why people are referred initially to pain management – and what they expect.  Allcock, Elkan & Williams explored, using focus groups, the beliefs, expectations and priorities of a group of patients referred for pain management.  Like my brief study a couple of days ago, they found that the majority of patients were looking for a firm diagnosis and a cure.  The patients they talked with believed there ‘must’ be a cause that could be found, that people around them wouldn’t believe that they had ‘real’ pain without being able to give a diagnosis, and that while they wanted pain killers at the same time they felt ‘just’ getting pain relief was ‘fobbing’ them off.  People didn’t know what to expect from coming to a pain management centre, and their focus was on reducing their pain – even if they felt just getting pain relief wasn’t enough.

Looking at this from a ‘stages of change’ model, my guess is that most people are in a precontemplative stage with respect to accepting that their pain is chronic, and that self management is a good option.  No wonder some people leave a centre feeling bitterly disappointed that the ’cause’ of their pain isn’t clear, and don’t fully accept the idea that self management is a positive option.

While the underlying pathology of chronic pain may change slightly over time, despite some advances in pharmacology, we don’t have an awful lot of medication options for many chronic pain conditions.  Options for something like fibromyalgia are really limited.  But ask someone with chronic pain if they ever stop hoping for ‘something, anything to reduce the pain’ and you’ll probably hear them say no!

Along with the hope for relief, there is a good deal of evidence in the literature that people who don’t feel they have a clear diagnosis, who are distressed or anxious about having pain, who expect that doctors ‘should’ be able to fix their pain, and many of those ‘yellow flags’ or psychosocial factors – these people tend to visit doctors more often than those who are more accepting of their pain.

Faced with a distressed and sometimes angry patient, a GP may well bow to pressure and want to start the process of referring for more investigations, another specialist opinion and yet another referral to pain management centre.

In one pain management centre I know quite well, up to 60% of the referrals received over a five month period were re-referrals of patients who had already been seen in the centre.  What that means is that only 40% of the referrals were for new patients – and given a waiting list cap of six months, it’s inevitable that some people will be turned away.

Now for some hard questions.

Why are people being re-referred?  Well, I actually don’t know in the case of this centre, information isn’t available.  Maybe this group of patients are more distressed, more depressed, more anxious than the average patient – at least, that’s what the literature suggests.  Maybe their health care providers are also more worried about pain, perhaps less confident to deal with people who are distressed.  Maybe their health care providers believe, like their patients, that there ‘must’ be a cause and therefore a cure for the pain.

If these patients have been to pain management before, why haven’t they adopted the self management model?  Maybe this is because they weren’t ready for it, or maybe the services they received weren’t effective (pain management lite, or low intensity pain management of less than 100 hours has been shown to have less effect than an intensive programme with an interdisciplinary team – according to Assoc. Prof. Mike Nicholas).

What is a tragedy is that many will be seen again and given another round of medications, perhaps they’ll get some more pain management – but without measuring the outcomes, we won’t know whether this is effective.  And they may well be re-referred in another 12 months because (1) they haven’t developed a sense of their own ability to manage their pain (2) their GP isn’t confident to support their self management (3) they got a sense of relief from distress at being seen by a ‘specialist’ (4) their GP thinks there ‘must’ be another medication that hasn’t been tried yet (5) and rarely, this time they’ve shifted from wanting something or someone else to manage their pain, and now want to develop self management strategies.

OK, I don’t know whether those reasons are true, they’re a hunch.  But what I do know is that the problem of re-referrals for a chronic condition clogs up health delivery, and that internationally a self management approach has the widest support for chronic conditions.  And yet time and again, people with chronic pain actually receive passive treatments, medication reviews, and more injection procedures.

A study like the Lamb, Hansen, Lall et al., one I’ve cited below demonstrates that even a six session group-based CBT programme of self management, delivered by physiotherapists, nurses, psychologists and occupational therapists (no discrimination here!) could provide effective outcomes that last even up to 12 months after the intervention.  In terms of efficiency (oh yes!) the CBT approach was more cost effective (cost per QALY) than acupuncture, exercise, manipulation, and postural approaches – all of which are supported in recent Clinical Guidelines in the UK and US.  It’s only a pity that a comparison between this approach and medications or injections wasn’t made.

Are these patients like the patients referred to secondary or tertiary pain management? Taking a look at their disability level, the duration of their pain, working status and age/gender – yes.  Is this an efficient way to help people cope with their chronic pain? It seems so – yet I wonder whether group-based CBT will survive in New Zealand.

Lamb, S., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E., Nichols, V., Potter, R., & Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis The Lancet, 375 (9718), 916-923 DOI: 10.1016/s0140-6736(09)62164-4

Allcock N, Elkan R, & Williams J (2007). Patients referred to a pain management clinic: beliefs, expectations and priorities. Journal of advanced nursing, 60 (3), 248-56 PMID: 17908123

Pain management in groups using a CBT approach: important therapist factors

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:

1. Didactic coursework/training in CBT models and techniques
2. Direct (hour for hour) supervision on multiple individual cases of CBT
3. Observational participation in a CBT group led by another therapist
4. 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:

1. They need to model ‘active participation’ – in other words, really be involved in the processes of the group
2. 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
3. Use collaboration and Socratic dialogue to guide participants through the process of discovery.  ‘Teaching’ doesn’t work well, ‘discovering’ works better, ‘experiencing’ works best.
4. 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.

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.

`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.

Goals, goals, goals

Today I had the challenge of working with a new group of participants in the Pain Management Programme. They’re with us for three weeks, and at the beginning of this time I say to them that if their lives are no different six months from then, it’s not worthwhile attending. Usually they’ll all nod happily in agreement, and I think to myself ‘good, now let’s get on and work out what they want to be different’. After we’ve worked our way through ‘get rid of my pain’ (and I make the quip about the magic wand in my office that’s a self management wand made of plastic), we start to work on goals.

My first step is to ask people to go through a list of possible areas that people with pain often want to focus on – things like learning to relax more, have a more consistent level of activity, communicate better with my family, accept my pain. Most people want to tick all the boxes on the list and end up with this enormous number of potential goals, so we have to whittle the list down a bit. I do this by asking them to choose maybe three goals that catch their eye – and emphasise that these goals are not the final ones they may choose to carry out at the end of the programme.

The main problem with these type of goals is that they’re not goals. Well, they are vague areas for learning about, but they can’t really be used as goals that can be achieved. They don’t have the characteristics that have been identified as most effective. The problem I find is that so few participants in the programme have ever learned how to set good goals. AND most people are both used to having someone else ‘set the goal’ and turn a dream into a series of actions, and fail to achieve these goals – I wonder sometimes if people are a bit fearful of the whole process.

A few months ago I started to look at goalsetting and whether it has been researched in pain management (there is a tiny bit of research, but not a lot) or researched in rehabilitation more generally (a little bit more, but again not a whole lot). I also looked at how well health professionals go about developing goals – whether participants generate goals, how long therapists spend establishing goals, and whether there was any consensus amongst team members about how to establish goals. Sad to say, there is a little research out there but it’s not a very popular topic, and what is known shows that goal setting is actually a high-level skill that many of us as health professionals either pay lip service to, or we focus on what we think should be achieved rather than what the person really wants.

The problems I’ve observed working with people to help them set goals are these:

• many haven’t set goals before and find the whole process challenging
• many haven’t looked forward for a long time, living day by day with pain as the dictator, so maybe feel fearful of committing to goals
• some have learned through past experience (like New Year’s Resolutions) that ‘goals don’t work’
• some have lived lives that drift and are relatively undirected, calling it ‘being flexible’
• some have no idea of what they CAN aim for
• some are grappling with accepting limitations to what they can achieve (this goal is too EASY they cry!)
• many don’t know how to break a goal down into steps they can do
• many have outcome goals that depend on other people’s actions, rather than looking at the things they can do (process goals)

Setting a goal up to be a series of actions that can be done takes a lot of time, knowledge about what each step needs to be, and for some people it’s the whole ‘pen and paper’ component that makes it challenging.

I’ve pondered whether it’s a good idea to establish a ‘real life’ goal at the beginning of a programme or nearer the end – I still don’t have a clear idea of which is best.  I do find, though, that participants resist setting ‘real life’ goals at the beginning of the programme – perhaps fearing being tied to something they may not achieve, perhaps because they don’t know how to go about them.  My current strategy is to work through the process I described above, then pick an arbitrary goal for the whole group (there is usually a common theme) and use it as an example as I work through the ‘SMART’ goal format.  Actually I have another acronym, ‘SPART’ – Specific, Positive, Actions, Recorded and Timetabled’.  This week I’m using ‘to identify one pain management strategy that can be used over the weekend at home’ as the goal.  Then that strategy can be used as ‘the goal’ for the weekend – giving another opportunity to write and achieve a goal.

I’d love to hear others talk about their experiences establishing goals, especially goals that are not about exercise, because I think those goals are reasonably straightforward.  It’s the ones about communication, developing good relationships, re-establishing a social life, developing an effective relaxation strategy and so on that I find more difficult to develop.  Let me know what you do!

Facilitating a group

Group-based approaches to pain management are common. They’re used not just for cost-effectiveness (because there are some ‘hidden’ costs to groupwork such as screening participants and team meetings), but also because some processes are better conducted in a group setting – such as observing others ‘well’ behaviours, learning vicariously from others’ experiences – and because experiential learning in a group setting replicates many of the work and family settings that people who experience pain will need to function in.

I use experiential learning, that is, the idea that change and growth take place when people are actively (physically, socially, intellectually, emotionally) involved in their learning rather than just being receivers of inforamtion. It’s not new – cognitive behavioural therapy has used this philosophy since its inception, occupational therapy is based on the idea that doing invokes being. I’ve no doubt many other health professionals also consider that active involvement in processing and learning is essential to integrating new behaviours. To carry out experiential learning, facilitation skills are vital, but again not training that health professions often seriously study during undergraduate study.

Today’s book is one of several I’ve recently obtained to refresh my facilitation skills. I’ve been lucky enough to complete a five-day training several years ago on facilitation run by Zenergy. Zenergy have a distinct philosophy about the value of teamwork, the synergy that occurs when people align to a common purpose and that cooperacy will achieve much for the whole world. For a list of their training courses, go here. Some of us, however, can’t take the time to go to formal training, or want a reference book, so I was pleased to find this book at Amazon.

Now, there is a saying ‘don’t choose a book by its cover’ and I would add ‘don’t choose a book by its title’ because the title is ‘The Secrets of Facilitation’, and that just smacked to me of cheesy pop psychology – but, perhaps surprisingly, this book has some very useable, practical ways for facilitators to ‘ask questions that ignite a bonfire of responses’, ‘discover the three reasons people disagree’, ‘resolve dysfunctional behaviour in four steps’ and ‘build consensus in meetings with five strategies’…

The Secrets of Facilitation: The S.M.A.R.T. guide to getting results with groups, written by Michael Wilkinson, published by Jossey-Bass, A Wiley Imprint: San Francisco, 2004. The book provides a model of group facilitation that incorporates both the flow of a facilitated session (preparing, starting a session, focusing the group, writing down resolutions, gathering information and finally closing the session – and includes asking questions to generate effective responses throughout the process); as well as the processes involved in group dynamics (how to manage dysfunction, build consensus, keep energy levels appropriate and set the agenda).

The book is not written for pain management, indeed it’s not written for health at all – it’s a business book aimed at helping teams function effectively so that group decisions are achieved and implemented (not that health teams EVER need to work on this, do they?). Despite this, so much of the book translates directly into both team functioning and group therapy sessions that I think it’s worth thinking about for your bookshelf.

What I like about the book is the straightforward language, the summaries at the end of each chapter, and the loads of example phrases and questions that you can immediately transfer into a clinical setting. Like many books, it includes some great tables that summarise the information – for example, a comparison of facilitator vs nonfacilitator responses listing what you might perceive (eg you don’t think what was said was correct), an example of both types of response, then a classification of the type of response that is recommended (eg Direct probe, indirect probe, leading question and so on). The diagrams have immediate appeal for me (I’m pretty visual!), and also help to give an overview of the construction of the book so you can see where each piece of the information given fits in.

What I liked less about the book is the example scenarios that relate to business or school settings, and so are not quite as easily transferred into the health setting – even though health can be considered a complex business enterprise! I also really dislike the ‘secrets’ concept. The book lists 60 so-called ‘secrets’, many of which are not exactly secret. I mean, do you think using energy-generating techniques throughout the session is a ‘secret to maintaining energy’?

Despite this somewhat tedious concept of ‘secrets’ the actual suggested strategies are effective. From the first chapter I picked up things I could use when facilitating group sessions on the pain management programme. Some good examples? Well, if someone comes up with an idea that you’re not sure about, acknowledge the contribution then ask them ‘how do you get around [X]’ and state what your concern is. He calls it ‘Building a PAC’ or listen, playback (reflect), agree (acknowledge the part/s that you can see merit in), then challenge or state your objection in the form of a question that allows the person to either solve your objection or to agree with it.
Another example is in using the whiteboard to record what participants say. The ‘secret’ is to write first (in other words, write down exactly the words the person says) then discuss what they’ve said. This ensures you as facilitator don’t imply that you know better than the participants, elicits more responses from participants who may otherwise begin to depend on you as facilitator for ‘the answers’.

If you want to help your team work together more effectively, or have a group of patients you’d like to help facilitate to achieve their goals – this book might just be what you’re looking for.

A week of book reviews

This week I’ve decided to review some of the books that I’ve recently bought for my bookshelf (not that they stay there!). Anyone who knows me will agree that I’m a bookworm, and the two most horrible websites (at least to my bank balance) are Amazonand Fishpond!

Onto today’s book – just arrived, although not a new book, published in 2006, it’s called ‘Cognitive behavioural therapy in groups’, written by Peter J. Bieling, Randi E. McCabe and Martin M. Antony. It’s published by Guilford Press, and I got mine from Fishpond at a cost of $58.25.

The reason I’m so pleased with this book is that for ages I’ve been looking for something to help with group processes and carrying out cognitive behavioural therapy. While groupwork was a core part of my training as an occupational therapist, and I’ve followed this up with facilitation training, many people working in pain management feel somewhat overwhelmed at the thought of taking a group. What can then happen is that the group sessions become almost an educational ‘lecture’ rather than a cognitive behavioural approach – which isn’t nearly as effective. We know that ‘information’ alone doesn’t necessarily change people’s beliefs or behaviour, and that people need to actively engage with and process new material to reconceptualise the implications of, for example, the fact that hurt does not equal harm.

This quite readable book has three parts – the first part is the most applicable to pain management, and covers the ‘General principles and Practice of Cognitive-Behavioural Therapy Groups’. There are six chapters that discuss why we might use a group approach rather than work individually with people; looks at how to use the inevitable group dynamics productively; then reviews cognitive strategies, behavioural strategies and a basic structure that can be used to implement CBT within a group setting. The final chapter in this section is about some of the problems and obstacles that occur in groups and how to overcome these.

The second part is much less relevant to pain management, and deals with nine mental health diagnoses and how groups have been used in these instances. It’s a shame that chronic pain groups were not included, because group therapy has been a fundamental of most cognitive behavioural approaches to pain management.

The final section looks at comorbidity and CBT groups and finally an FAQ section. There is an extensive reference list (forty pages!), and the whole book is well-indexed.

So, let’s take a quick look at the chapters in Part 1.
Chapter 1 – CBT groups – possibilities and challenges. Several reasons have been put forward for conducting CBT approaches in a group rather than individually since the early days of CBT. Of course the main reason initially given is that it is more cost-effective than working individually with people, but there are other good reasons to consider this way of delivering CBT such as the way that people learn vicariously (ie by watching and learning from what other people say and do) and the way in whcih people can feel less isolated when they meet others with similar problems. The chapter reviews several models for analysing group process from outside the CBT framework and applies these to the specific requirements of the CBT approach. It particularly defines ‘group process’ and ‘CBT technique’, with technique referring to the learning tools and methods people use to review their thoughts, beliefs, emotions and behaviours in order to make changes, while process refers to the interpersonal interactions among and between group members and facilitators.

Chapter 2 – Group process – This chapter very clearly describes a number of the group process dynamics that occur longitudinally as group members and facilitators interact. These processes may directly influence self disclosure, a sense of optimism, reduce isolation, moving from a ‘self focus’ to a focus that includes others, direct modification of behaviours (particularly applicable in relation to reducing pain behaviours), and group cohesion and emotional processing. I particularly liked a table included in this chapter that identifies the process factor, defines the factor and summarises how to positively influence and use the process for client change. Some very good dialgoues are provided to illustrate ways to attend to group process while carrying out some of the basic CBT techniques within a group setting. I’ve learned some good things about how to structure my responses to facilitate better group participation especially around home learning review. The last part of this chapter considers the longitudinal development of group development and presents another wonderful table identifying the ‘stage’ of the group and effective therapist responses to ensure the CBT approach is maintained throughout.

Chapter 3 – Cognitive strategies within a group setting. This chapter explains the range of cognitive therapuetic techniques such as guided discovery, collaborative empiricism and Socratic dialogue, and provides an overview of how these can be applied. Once again it uses dialogue to guide through examples of how this might work in a group – and although the examples are specific to mental health issues, they can still be applied in most cases to people with chronic pain.

Chapter 4 – Behavioural techniques in a group setting. It’s good to look at both the advantages and disadvantages of groupwork for CBT, and this chapter reviews this very briefly. Basic behaivoural approaches such as exposure therapy, behavioural self monitoring, using the group to monitor each other’s behaviour and so on are discussed in the chapter, but I have to say I think there are more aspects of behavioural therapy that can be used than are described in this chapter, as well as more challenges than are discussed.

Chapter 5 – Structre and organisational issues. Now this is one chapter everyone should read before starting to take a group CBT programme! Four aspects vital to effective group programme management are discussed: participant selection, therapist factors, between-session structure and within-session structure. The emphasis is on learning and experience both within the group, and the chapter makes it clear that balance between all aspects of both group process and CBT technique is needed throughout. A good solid read on the ‘how to’ of administering a group-based CBT programme.

Chapter 6 – Problems. Another chapter that everyone should read – or will want to read because it has answers! I can’t think of a single group where at least one of the issues that is discussed in this chapter has not occurred. From having a dominating group member to someone who speaks on behalf of the others to ‘help’ to someone who rarely turns up or appears disinterested…hmmm sound familiar? Like some of the other chapters, it has a great table describing various member behaviours and appropriate therapeutic responses to them. The final section deals with group process that derive from aspects of the CBT model such as didactic aspects of some parts of therapy, the very structured approach that CBT sessions take, the need for some ‘outside of group’ sessions in certain circumstances, and how to deal with trainees and non-group people observing.

To summarise: while the second part of this book may not necessarily directly apply to people taking pain management group sessions using a CBT approach, the first part is, I think, essential reading for anyone wanting to really apply CBT within a group setting. The writing style is straightforward, the example dialogues very helpful, and summary tables really clear. There are heaps of references (if you’ve ever had to justify having a co-therapist to your manager, you’ll appreciate some of them in particular!), and the FAQ section answers yes, some of those really frequently asked ones! This is a book I just wish had either included chronic pain groups, or was published in two volumes so the first part was available in a stand-alone edition.

Great group activities resource

I stumbled across this great site full of activities for developing group dynamics through experiential activities.  There are loads of free downloadable pdf docs on activities that are fun, require very little in the way of materials, and are pretty simple to carry out (well, as simple as any group activity is!) and can be aimed at various levels of reflection or self discovery.

I especially found the section on Exploring the Five Stages of Group Formation helpful, and recommend this for anyone who is working with a group of people over several weeks.  I think so many group programmes are simply 1:1 sessions carried out with a lot of people rather than truly becoming the synergist venues for developing as people and achieving goals that they really can be.

Pain Behaviour Activity

Having looked all over the place for some suitable activities for people to become aware of their own pain behaviour and then learn to change it, I decided to put together one of my own. Now, unlike the posts I’ve made recently, I have no research to determine its effectiveness, but I hope you’ll forgive me for this!

The basis for considering behaviour change in pain management is behavioural psychology – by selectively reinforcing ‘well’ behaviour, pain behaviours should reduce in frequency. And it certainly does work – by simply asking someone ‘what have you been up to recently’ rather than ‘how is your pain’, we are able to reinforce activity rather than elicit a list of woes! But because I also want people to develop their own awareness of their behaviour so they can independently choose to alter their patterns, I think it’s helpful to

1. become aware of what may be relatively automatic patterns
2. start to alter one behaviour at a time
3. use behavioural principles to reward well behaviour

This is the activity I chose, and a variation.
In pairs, I asked the group to ask each other this question:
“How do you know when I’m having a bad day? What do I do?”
I also gave them a list of pain behaviours to use to help them identify specific behaviours they may do.

Then I asked them to complete their own personal ‘pain thermometer’. You know how people often say they don’t have a thermometer or a plaster cast to say they have pain – well their behaviours can certainly act as a thermometer to other people!

In this activity, the thermometer is copied onto A3 paper, and the list of words and pain faces given to them to paste onto the thermometer. In pairs, they are asked to complete a pain thermometer to reflect the pain intensity and pain behaviours that they do.

The idea is to give the participants an opportunity to reflect on the range of pain behaviours they carry out, and to consider the effect on each other.

I also asked the group to carry out one of their pain behaviours to the extreme – walking from one side of the room to the other with these exaggerated behaviours. Asking the group to discuss what it was like revealed some interesting insights like ‘I don’t know what I do when I’m really sore’ to which another participant demonstrated exactly what that person does! And another said ‘I never knew how hard it was to move and how frustrating when I do these movements’.

Then I asked the group, in pairs, to choose one behaviour and discuss the impact it has on them and others – the good things about it and the not so good. Participants identified that pain behaviours can act as a warning sign to others, that they communicate very well – but have unintended effects that are not so good, like people either avoiding them, or ‘smothering’ them!

Then they chose that one behaviour and decided to spend a day learning how often they actually do it – and because they are in a group, learning to remind each other when they inadvertently revert to old habits.

All in all, I think this was an interesting activity – and hopefully will have at least increased the awareness of pain behaviours in this group. Changing the behaviours – that will take time!
If you use this activity, let me know how it works for you – and any modifications you may.