Group Psychotherapy for Chronic Pain Patients
Several years ago, I had quite limited time available for direct clinical work with patients with chronic pain. As the waiting time for a new appointment increased, so too did my discomfort with asking patients in urgent need of help to wait for treatment. It finally occurred to me, as I taught the same basic pain management skills to each patient, that it would be more efficient to do this work in a group setting. Thus, my first pain management group was started…and I’ve been doing them ever since. However, my reasons have changed—I continue to do group work because it’s so effective. What started as an effort to be of service to more patients has continued because I believe it is a key modality for successful treatment.
Group Psychotherpy Program
The basic structure I use is an 8-week group psychotherapy program that combines teaching pain management skills and supportive psychotherapy (see Table 1). Skills such as focused breathing, muscle relaxation, visualization of relaxing settings, and guided imagery are taught, and patients practice these skills between sessions. These skills serve to decrease anxiety, and decrease pain levels both indirectly (e.g. through muscle relaxation) and directly (e.g. through guided imagery with suggestions of decreasing pain). Patients can problem-solve together about impediments to using the techniques. For example, if one person reports difficulty in finding time to practice the techniques, others can share how they manage to do this. Patients also share variations of the exercises they’ve developed on their own and find more helpful. There also seems to be some positive peer pressure to practice the exercises between sessions when most others in a group do so.
|Session 1: Relaxation I. Learn a basic relaxation exercise, with breathing and muscle relaxation.|
|Session 2: Relaxation II. Add visualization to the basic relaxation exercise.|
|Session 3: Coping Styles. Identify positive coping styles, such as active management of pain, acceptance of one’s current state, and humor.|
|Session 4: Coping with Changes in Your Life. Identify ways to cope with the difficult consequences of a pain disorder, such as decreased independence, and loss of work or activities.|
|Session 5: Guided Imagery I. Learn a guided imagery technique to decrease pain.|
|Session 6: Guided Imagery II. Personalize the guided imagery technique.|
|Session 7: Medications and Alternative Medicine Options. Identify ways to achieve the most benefit from medications and to manage side effects. Learn about alternative medicine options.|
|Session 8: Spirituality, Pain and Suffering. Identify spiritual resources to cope with pain.|
Advantages of Group Modality
What I find to be the most powerful and therapeutic aspect of the group, however, is the supportive psychotherapy. Patients have a significant amount of time during the group sessions to share their challenging, difficult experiences with others who are going through similar experiences. Patients talk about the effects of chronic pain on their work lives, relationships with family and friends, and hobbies and leisure time. Patients also share what positive coping skills they’ve used or learned, both in terms of their attitudes towards their situation as well as specific ways to continue living their lives. For example, an attitude of acceptance is positive, “I don’t like some things about my situation right now, but I’m coming to terms with the fact that this is how it is for the moment.” Use of humor is encouraged.
Modifying aspects of their lives is often needed, to be able to reach previous goals, but perhaps by new means. For example, one patient had previously enjoyed gardening in her yard, but was physically unable to do as much. She decided instead to do several container gardens on the steps in front of her home, as planting in the dirt and nurturing growing things was important to her. Other options could have been directing the process while a gardener did the actual work or visiting public gardens. One Dad had been the coach for his son’s after-school sports team, but now was unable to walk up and down the field. He decided to get involved with fundraising for the team, to watch the games, and to take his son to professional games instead. What was important to him was sharing his son’s enjoyment of sports. In a group setting, more creative ideas can be generated. Common themes are identified, such as the need to pace activities, to care for the self, and to listen to one’s body.
The advantages of the group modality for this work are many, and include the following:
- The isolation of having a chronic pain condition is lessened. Patients hear, sometimes for the first time, that others know what “pain 24/7” means, and that others sometimes struggle to cope also. It’s reassuring for some patients with lesser-known diseases such as CRPS/RSD to talk with others with the same symptoms.
- Patients can problem-solve with others on ways to decrease pain and cope with the consequences of chronic pain.
- Patients experience helping others, when they may have only been in the “helped” role.
- Patients’ support networks are expanded.
- Resources and information can be shared.
Several potential problems with pain management groups need to be guarded against. The group shouldn’t become a setting in which patients simply complain or see who has the worst pain.
While sharing difficult experiences is very helpful, the focus should be on coping with pain. Patients need to be able to participate appropriately in a group, being able to share their stories as well as listen to others, and be able to learn and practice the skills taught. Screening patients prior to group therapy is important.
Patients with significant psychiatric symptoms, e.g. severe depression or suicidal thoughts, should be treated individually first, so they can reach a point where they can both benefit from a group and avoid harming the group dynamic. Good group therapy skills on the part of the therapist are crucial to create a therapeutic experience for patients.
A group program is often an adjunct to individual work, where a patient’s personal situation can be explored in more detail. I believe group psychotherapy is a vital component of comprehensive treatment to help patients decrease their pain and reclaim their lives.