programme

Group facilitation


I love working in groups! I love the diversity, and the way that learning occurs, and the challenges of energising and focusing groups. For me groupwork is one of the most demanding and yet rewarding aspects of my work.

There are many many sites on the internet that have a range of activities for groups – a good number of them are free. What they don’t seem to do is help with how to integrate the activities so they not only energise and warm a group up, but also provide a venue for serious learning.

I’m going to describe two activities that I’ve enjoyed using with groups who are developing pain management skills.

The first is used within the first week (often the second or third day), and the second is best used towards the end of a programme. The purpose of each activity is to allow the group to focus on the activity while forgetting about their pain, so that they can develop awareness of what their ‘high risk’ behaviours are with regard to learning new activities, integrating pain management strategies, and in a sense, how they live their life. I subscribe to the idea that ‘how you do anything is how you do everything’ – so how people participate in these activities is probably how they will respond to situations in the real world.

There are some common tasks as facilitator for both activities, and I’ll describe these as a preamble to the specific activities.

The purpose: to enable the group members to respond naturally to a ‘demand’ situation, to assist them to reflect on the way they approach activities (‘life’)

My role: facilitate, set task parameters, enforce ‘rules’ or boundaries, assist the group to reflect and generate their own learning, ensure the equipment and environment is established for mental and physical health

Pre-activity: set up environment, ensure the instructions are printed and clear, ensure all equipment is available, have stop-watch or timer set up, and that adequate time for both briefing and debriefing has been allowed for.

Post-activity: ensure all participants have had time to reflect, all have been facilitated to hear what you as facilitator think is important, and that group process has been allowed to flow, the participants have written down ‘key learnings’ from the session, and you have been able to clean up.

Group size: 4 – 9 participants

Activity one – ‘Crossing croc-infested waters’

Materials: 5 A4 sheets of paper, tape to mark floor

Preparation: tape a ‘river’ across the floor – the ‘river’ should be at least 3 m wide, and about the same deep (or as wide as your room!)

Instructions: Tell the group that they are required to cross the river which is full of crocodiles. They have five stepping planks that they can use to cross the river with, but because they’re made of wood and float, once they are placed down in the water, they must be held down with a foot at all times or they will be swept away! The group must rely on each other, and work out how to get all members of the group across the river safely using only the five pieces of paper. They must not allow anyone to ‘die’, neither can any part of their body touch the ‘river’ or it will be ‘eaten’. They have 10 minutes to complete this activity.

Facilitator role: It is very important to enforce that the pieces of paper must be held down at all times. This is often forgotten unless the group have rehearsed the activity on ‘dry land’, and learning to rely on each other and work together as a team, watching out for each other and coordinating their movements. The facilitator must also urge speed and maintain a watch on time, particularly as the activity nears the end. To make the task more difficult, the time can be made shorter, or a piece of paper can be removed. It’s also important that no-one puts their foot in the ‘water’ (or they may not put that foot down again – it’s been bitten off!)

At the end, the facilitator must conduct the debrief – see attached pdf doc.

Activity two – Radioactive Rice

Materials: two cups, one filled with uncooked rice, various items from around the room including sheets of paper, tape, spoon, icecream sticks, pottles, string, bluetac, chalk, instruction sheet

Preparation: draw a circle with chalk on the table (circle is usually about 1m radius). Place one cup filled with rice in the centre of the circle. Collect other assorted items around the table.

Instructions: Tell the group that this is a heavily disguised cup of radioactive rice that will blow up in 30 minutes, creating a huge crater of radioactivity and killing all within a 2km radius of the area. Inside the chalk circle is an invisible containment field shaped like a cylinder, going from ceiling through the table to ground level. This is currently holding the radioactivity inside it. The rules are:

  • No body parts are allowed to enter the containment area
  • No-one is allowed to commit suicide and sacrifice themselves to remove the rice
  • No items that are outside the room are allowed to be used
  • Anyone who breaks the rule is ruled out and cannot be physically involved from then on (not the word physically involved! it’s OK to talk…!)
  • As much or as little rice can be transferred at any one time
  • The group has 30 minutes to transfer the rice from one cup to the other, then to remove the second cup to the ‘safety zone’ before the whole area will blow up

I usually allow 5 minutes question time then I will stop answering any questions and allow the group to get to work.

After 30 minutes, time is up and it’s debriefing time.

Facilitator role: It’s very important to stick to the rules at all times, maintain a very close watch on the participants and firmly tell them they are out if they break the rules. Every 5 minutes for the first 15, count time, thereafter every one minute, and in the last two minutes, every several seconds. Ensure people who are ‘out’ don’t get physically involved – but remember they are allowed to remain in verbal participation! Managing the debrief is essential.

Debriefing: for both of these activities, debriefing is essential!

In each case, these activities represent ‘life’ – and how people go about managing their participation is very similar to how they will participate in ‘real life’. So, some people will work together with others, think and plan, and manage both themselves and their pain using a wide range of skills. Others will completely forget to manage their pain, jump right in and break the rules very quickly.

This document (activity-review-jan-2008.doc) can be used for individual review.

As well, the group can be facilitated to provide review to each other – this is a very powerful way for people to develop knowledge of each other, and to learn to give and receive feedback (positive and negative). I usually start with asking the group ‘what did you do well?’, and ‘what would you do differently?’, then I ask the group to contribute both types of feedback, and finally, ask the person ‘what will you take away from this experience today?’.

Often it’s helpful to reflect on ‘what happened when I was counting the time down?’ – it’s adding pressure, and mimics a working situation.

Asking ‘and what happened to your pain during the task?’ reminds people of the usefulness of distraction, and that it can be a trap because pain becomes more problematic afterwards. Most people forget to use pain management strategies, so it can be a potent learning tool to remind them that they need to integrate pain management strategies even during activities like this that are involving and distracting. I also like to remind people that they always had a choice – they could have told me that this activity was silly, not real, and chosen not to participate! But they may have missed an opportunity to learn something – which is pretty much what life is like!

Reflecting on ‘What did it feel like when you were told you were out?’ is a powerful experience – many people say that they felt gutted, stunned, angry, and some argue against the rule. It’s useful to draw the parallel with the experience of suddenly having pain, when all the physical things they used to do were restricted (but equally powerful to emphasise that people were still able to contribute verbally – many people don’t remember this, and it can be both humbling and empowering for people to realise that they self-limited their involvement by not clarifying their position).

At the completion it’s important that participants write down their take-home messages – it’s impressive how many are aware even at the beginning of a programme, exactly what their particular pain management ‘trip-ups’ will be, but equally impressive to notice that even by the end of the programme, they will still fail to integrate their skills.

I hope you enjoyed this introduction to two activities I’ve used with people to help them learn experientially.

Pain management can’t be cloned


I’ve had occasion over the past few weeks to think about service delivery and teamwork and how to provide really good pain management programmes in a group context.

A problem with any interdisciplinary team is that the members of the team may change as staff leave, or are unwell, or even have annual leave(yes! we like to take a break too!). At the same time, programmes for people with pain need to be provided consistently and often enough to break even financially.

The economic viability of interdisciplinary group pain management has been established (see these papers by Gatchel & Okifuji (2006), Goossens, Rutten-Van Molken, Kole-Snijders, Vlaeyen, Van Breukelen, & Leidl (1998), Turk & Burwinkle (2005) for discussion), and we know the effectiveness of this approach on individuals from too many studies to list here. Often however these outcomes can be overlooked in the face of the need to resource a programme with professional staff members, facilities, administration, outcome measurement, and ongoing review and development. So managers sometimes think of ways to reduce the cost in the most expensive resource – the staff members and the time spent on reviewing and developing programme content.

The argument seems to be one of two:

  1. That once a programme has been developed, there is little need to review it, and a ‘cloning’ approach can be used (similar to a franchise strategy!)
  2. That once the programme has been developed, the professional involved in the programme can simply ‘teach’ the contents – and perhaps ‘any’ professional can do this…

Let’s take a look at the first argument – that programmes can remain essentially the same once they’ve been set up. I’d argue that because pain management is continuing to evolve and develop, it becomes foolhardy not to include the findings and ‘technology’ based on new research findings. For example, in the last 5 years the literature on the pain-related anxiety and avoidance model (Vlaeyen & Linton (2006) has rapidly established the place of behaviour change and exposure-based therapy for people who are fearful of movement or pain. Programmes ignore pain-related anxiety and activity avoidance at their peril. Review and update are necessary in all areas of health care – no less so in pain management.

The second reason, that therapists can be slotted in and out of programmes as required – provided that they can ‘teach’ the content, suggests that the technical needs of cognitive behavioural therapy have been misunderstood. CBT is not simply providing information to people – it is a process of reconceptualising concepts, developing and rehearsing new skills, and reviewing situations to problem-solve and develop strategies so that the next encounter can be successfully managed.

As I’ve written about before, interdisciplinary teams need certain things to be effective – these include

  • a common model that all members of the team are well-versed in
  • technical skills in providing cognitive behavioural therapy
  • group facilitation skills
  • knowledge and trust in each other as professionals
  • ability to work across professional boundaries as necessary so as to reinforce the common model

To achieve this state, I think these things are essential

  • really good induction
  • time together as a team
  • agreement to adhere to the programme process
  • systems and structures to support decision-making
  • opportunity to observe the team members and programme

It is simplistic to think that the best way to ensure an economically viable programme is to reduce costs in the areas in which the ‘technology’ resides – the therapists and their skill, and ongoing review and development of the programme.  Not to mention time and processes to develop teamwork.   Although it’s expensive up-front, this time and effort is recouped in the quality of the programme and the outcomes it achieves.

On a slight tangent – can a successful programme from one country be transplanted holus-bolus into another country across the other side of the globe?

Some things concern me about this – the ‘franchise’ approach which prizes adherence to a manualised approach and can prevent ongoing development; the belief that professionals in one country have the same background and training as in another country (especially with respect to occupational therapy training!); the thought that patients can be cloned and ‘one size fits all’; and finally the suggestion that the active ingredients in the programme will ‘fit’ with the social, economic and political climate in another country.  I don’t know that this is achievable in chronic pain management…and wait to see with a good deal of interest whether it can happen here in New Zealand.

Let me know what you think about this post – agree? disagree? want to point out arguments for and against? Bring those comments on!!

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain.[see comment]. Journal of Pain, 7(11), 779-793.

Goossens, M. E., Rutten-Van Molken, M. P., Kole-Snijders, A. M., Vlaeyen, J. W., Van Breukelen, G., & Leidl, R. (1998). Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Health Economics., 7(1), 39-51.

Turk, D. C., & Burwinkle, T. M. (2005). Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers. Professional Psychology: Research and Practice, 36(6), 602-610.

 

Vlaeyen, J. W., & Linton, S. J. (2006). Are we “fear-avoidant?” Pain Vol 124(3) Oct 2006, 240-241.