DAAC 2354: DYNAMICS OF GROUP COUNSELING
Human Services student Beth Beethe designs an original therapeutic support group for chronic pain sufferers based on her experiences and work with clients. She researched newer forms of non-narcotic treatment approaches, designed to help individuals reduce their dependence on addictive medications, and provides a logical rationale for their use. Group sessions are methodically structured and supported with clearly defined terminology and objectives. Throughout the manuscript, there are connections between her ideas, rationale, and research-based treatment approaches.
– Cynthia Trumbo
Non-Narcotic Support Group for Chronic Pain Patients
This support/educational group focuses on helping patients that are using narcotics to reduce the amount of chronic pain they deal with by teaching new ways to manage pain without narcotics. An estimated 116 million adults experience chronic pain (James, 2011). Respondents of a National Institute of Health Statistics survey indicated that low back pain was the most common (27%), followed by severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%)” (Medicine, 2006). All the members are inpatients of varying ages in a Pain and Recovery Center, dealing with chronic pain stemming from different types of injuries or illnesses. Support/educational groups “enable members to learn that other people struggle with the same problems, feel similar emotions, and think similar thoughts” (Jacobs, Masson, Harvell, & Schimmel, 2014, p.15). The goal is to teach members to learn to think differently, to lower the amount of pain being felt and to find different ways to handle chronic pain. This is accomplished by first removing the dependence on narcotics that were no longer aiding in or providing pain management. Second, teaching new methods of controlling pain. Third, to create a support/educational group where the patients can open up about their fears of detoxing and living without the narcotic/controlled substances. And lastly the patients will learn new ways to schedule their days instead of around their pain, through their pain.
The duration of these 90 minute sessions will be four weeks, twice a week, for a support/educational group for patients in a residential treatment center for managing chronic pain without the use of narcotics. The group caters to all adult patients of the facility, both male and female. Each patient is given confidentiality information upon admittance.
Outline for Eight Group Session:
The leader discusses with the members that one of the reasons for confidentiality is to maintain a safe environment for the members to share and be able to have the expectation of privacy outside of the group itself. The guidelines are formed on the first session of the support group and include but are not limited to no cross talk, no “rescuing” other members (offering sympathy or grabbing a tissue for them when they are emotional) to allow that member to truly feel the emotions at that time, one person will speak at a time, members should speak in “I” phrases only, respect the other members within the group, do not make comments that are intended to hurt or cause pain in another member, when giving constructive feedback do so in a kind manner, and participation is mandatory but the extent of that participation is defined by each member for themselves. The Confidentiality statement and the guidelines that the group will use are called “stating the norms”. In a round each member tells their name, the cause of their chronic pain, and on a scale of 1-10, with 1 being the lowest and 10 being the highest, identify what is their current pain level. This is referred to as the “name your pain” round.
The “stating the norms” and the “name your pain round” are repeated at the onset of the sessions. The leader keeps the focus of the sessions on the subject of removing the narcotics and dealing with pain in a different manner to keep the group from wandering off topic into storytelling about how many pills they took or what medications they were on.
Purpose: To introduce the members to the concept of managing pain without the use of non-narcotic/controlled substances. To establish the group’s overall purpose and what each member hopes to learn/gain from the group. To introduce the members to each other and begin building a therapeutic and safe environment for them to begin rebuilding their life.
Theme: “Lower the Medication – Lower the Pain!”
Activities: The leader begins the session with the “stating the norms” and “name your pain” round. In this session, it is imperative that each member get to know the other members in the group so that in the future they will feel comfortable sharing personal feelings, beliefs and experiences. There is a second activity to further engage the members with each other and help them get to know one another on a deeper level. The leader will break the group into dyads. Each dyad quickly discusses what each member wishes to get out of the group and any concerns they may have about being in the group. Finally, the dyads regroup back into a circle. Each member introduces their partner’s and what they hope to gain by being in the group and any concerns they have shared. This continues from dyad to dyad until everyone’s comments have been shared. The leader facilitates a discussion about these concerns allowing everyone to participate as solutions to these concerns are reached.
Purpose: To introduce Cognitive Behavioral Therapy (CBT) and the Gate Control Theory (GCT) of pain management and have an open discussion on the merits of these theories. “Cognitive Behavioral Therapy (CBT) is based on the principle that one’s thoughts cause one’s feelings.” (Jacobs, et al, 2014, p. 15).
Theme: “Retrain Your Brain ”
Activities: The leader initiates the “name your pain round” and “stating the norms”. To emphasize CBT the leader discusses how automatic thoughts tie into CBT and changing the way you feel or behave. “Anyone can develop depression if he or she is living with chronic pain. Getting counseling can help you learn to cope better and help you avoid negative thoughts that make pain worse — so you have a healthier attitude. Asking for help is a sign of strength, not weakness” (Lava, 2015). A good way to avoid negative thoughts is discussed and the leader hands out “homework” in the form of a paper with a column for ”Negative Thought” and a column “Replace Negative Thought”. This activity helps members learn that thought processes can affect the way they think and that a negative thought will produce negative feelings as well as a positive thought will produce positive feelings. At the end of the session the homework is to write down five negative thoughts that they believe about themselves and replace each negative with five positive thoughts that they believe about themselves and bring the paper back to the next session.
At this time, the leader moves on to discuss the Gate Control Theory (GCT) (Viatcheslav Wlassoff, 2014) for the rest of the time allowed. The leader talks about the fact that chronic pain patients have the highest and lowest pain thresholds. Using the GCT the leader discusses how the injured limb sends messages to the brain “telling” it that it is in pain. The brain has grown accustomed to putting all pain signals in a chronic pain “bucket” and will do so with any pain that develops. “The pain signal transmission can be influenced by emotions and thoughts. It is well known that people do not feel a chronic pain or, to be more appropriate, the pain does not disturb them when they concentrate on other activities that interest them. Whereas, people who are anxious or depressed feel intense pain and find it difficult to cope with it. This is because the brain sends messages through descending fibers that stop, reduce or amplify the transmission of pain signals through the “gate”, depending on the thoughts and emotions of a person” (Wlassoff, 2014). If the member can stop the message from getting to the brain, as if a gate is closed in their “throat” (brain stem) stopping the signal, and then think the pain through before deciding if it is chronic pain or not, then the patient can react differently to the current pain (Wlassoff, 2014).
Included in this discussion is the use of biofeedback. Using biofeedback training with a biofeedback handheld machine to show the body’s reaction to relaxation techniques used in biofeedback in “real time”. The leader helps the members learn and test their own abilities of biofeedback. This also shows the members how much their thoughts can control their body. For members, the biofeedback machine acts as a kind of sixth sense which allows them to “see” or “hear” activity inside their bodies.
Purpose: To go over the homework activity from the previous session and discuss how it made the members feel when they replaced the negative self talk with positive. Discuss with the members if they can see how thinking about a pain (referencing the previous session GCT) can help them handle the pain in a manner more realistic when dealing with a “lower” pain such as stubbing their toe or hitting their elbow on a hard surface. Once established that not all pain is chronic and not all pain requires a pill, the leader then directs the discussion towards living a fuller life by paying attention to the actual cause of a pain and handling each pain differently.
Theme: “Live Life”
Activity: The leader initiates the “name your pain round” and “stating the norms”. The leader opens the floor to allow the members to tell about their negative and positive thought process and if anyone feels better about themselves after doing the assignment. This will open up the subject of “thinking causes feeling” and give the leader an opening to discuss pain and the GCT in further detail. The leader allows for some continued discussion and directs the group towards self-care and things that the members can do encouraging members to also talk about things that are hard for them to do and finding new ways to attack those issues in a positive way.
Purpose: Alternative ways to deal with pain. The leader discusses how to free the mind and focus on relaxation through meditation.
Theme: “Change Your Focus”
Activity: The leader initiates the “name your pain round” and “stating the norms”. The leader discusses the benefits of meditation. Each member is given a mat to lay down on and a pillow. The leader directs the members to think about a peaceful quiet place that they feel comfortable and free of pain. The leader lowers the lights and starts quiet peaceful music while directing the members to feel the peace inside their minds and focus on that peace. The leader directs the meditation for 70 minutes. The leader slowly ends meditation and quietly discusses with the members, through the end of the session, what their pain level is after the meditation. This shows the members how focusing away from their bodies can actually help to lower their pain level.
Purpose: To introduce members to another alternative way to deal with pain. The leader, along with a Yoga instructor, helps the members to stretch their muscles, build their core strength and learn to utilize their own breathing to help focus on something other than their own pain through yoga.
Activity: The leader initiates the “name your pain round” and “stating the norms”. The leader brings up and discusses the meaning of a common Yoga term kintsukuroi”Kintsugi (金継ぎ?) (Japanese: golden joinery) or Kintsukuroi (金繕い?) (Japanese: golden repair) that is the Japanese art of repairing broken pottery with lacquer dusted or mixed with powdered gold, silver or platinum…. As a philosophy it treats breakage and repair as part of the history of an object, rather than something to disguise…. Not only is there no attempt to hide the damage, but the repair is literally illuminated… (Kintsugi, 2015). The belief is that something that has been broken and then repaired, using precious elements such as gold or silver, has more value than the original thing.
Before turning the class over to the Yoga instructor, the leader reminds the group that there is no competition in Yoga and to not push themselves farther than their bodies allow. The rest of the session is Yoga.
Purpose: To educate the group about the importance of eating healthy.
Theme: “You Are What You Eat!”
Activity: The leader initiates the “name your pain round” and “stating the norms”. The group leaves the normal assigned room for group to a greenhouse on the facility grounds. The leader introduces the groundskeeper/greenhouse manager and turns the group over to him/her for discussion on downfalls of bad nutrition. After being in the greenhouse for about 30 minutes the group will return to the room and the leader discusses healthy foods that can also reduce pain. When talking about medications to aid in pain relief “there is an alternative, and it’s right in your kitchen. Certain foods ease aches by fighting inflammation, blocking pain signals, and even healing underlying disease. Almost always, if we find pharmaceuticals doing the trick, we’ll find a plant doing the same trick—and doing it more safely,” says botanist James A. Duke, PhD, author of The Green Pharmacy Guide to Healing Foods (The Green Pharmacy, 2015). No fruit, vegetable, or herb by itself can alleviate your pain if you don’t change the pattern of your diet to reduce processed food and increase whole foods” (Neithercott, 2014).
Purpose: To discuss addiction as a disease and familiarize the members with support groups that are available through several outside facilities such as Church groups and 12 step programs.
Theme: “Addiction: Disease or Moral Choice?”
Activity: The leader initiates the “name your pain round” and “stating the norms”. After a 30 minute discussion about addiction and how it is a disease, the group is directed to a 12 step AA meeting that is held on the premises for the duration of the group.
Purpose: To say goodbye to the graduating members and discuss IOP and Aftercare.
Theme: “Critical Continuum Care”
Activity: The leader initiates the “name your pain round” and “stating the norms”. The leader gives an explanation of Intensive Out Patient (IOP) and Aftercare (AC). After pointing out the members that are leaving the group for IOP or AC, the leader opens a discussion of relapse prevention. The leader directs the group to discuss what techniques they learned that helped them relieve their pain. The group is prompted by the leader to discuss what each exiting member’s current pain level is and where it was when they first came into the group. This discussion is group run unless the leader needs to redirect the focus of the group to the exiting members.
STRATEGIES TO EVALUATE THE GROUP
“The final 10-15 minutes of the eighth session consists of a group evaluation; the members fill out a survey detailing their experiences (See appendix).
This support/educational group is designed for adults in chronic pain that have been medicated or overmedicated by their pain management doctors. The purpose of this program is to detox the patients of the controlled substances and to educate them with new ways of dealing with pain management. With a focus on CBT, meditation, Yoga, and Nutrition and other alternative ways, each session is designed to give the patients a new way of looking at pain. By educating the patients, they will find good ways to refocus their mind and deal with pain without the need to turn to narcotics/controlled substances. It is imperative for the patients to be their own advocate and to question the methods that have been being used for the past decades to restore each person with a renewed, higher quality of life.
Survey from Session 8
Non Narcotic Pain Management Group Survey
Rate on a scale of 1 to 10 the effectiveness of this group (1 being the weakest, 10 being the best). 1 2 3 4 5 6 7 8 9 10
Rate on a scale of 1 to 10 the effectiveness of this leader (1 being the weakest, 10 being the best). 1 2 3 4 5 6 7 8 9 10
- Rate on a scale of 1 to 10 how helpful this group has been (1 being the weakest, 10 being the best). 1 2 3 4 5 6 7 8 9 10
Use the following space to share any personal thoughts regarding this group or the leader. ___________________________________________________________________________________________________________________________________________________________ (Preece, (Preece, 2015)
Jacobs, E.E., Masson, R.L., Harvell, R.L. & Schimmel, R.J. (2014). Group Counseling Strategies and Skills. Belmont, California: Brooks/Cole.
James, S. D. (2011, June 29). ABC News. Retrieved from Chronic Pain: http://abcnews.go.com/US/chronic-pain-americans-live-iom-report/story?id=13950802
Kintsugi. (2015, October 18). Retrieved from Wikepedia: https://en.wikipedia.org/wiki/Kintsugi
Medicine, A. A. (2006, January 1). The Voice of Pain. Retrieved from American Acxademy of Pain Medicine: http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#refer
Neil Lava, M. (2015, February 22). 11 Tips for Living With Chronic Pain. Retrieved from Web MD: http://www.webmd.com/pain-management/guide/11-tips-for-living-with-chronic-pain
Neithercott, T. (2014, June 5). 10 Healthy Foods That Fight Pain Naturally. Retrieved from Health: http://www.prevention.com/health/health-concerns/10-healing-foods-fight-pain
Preece, H. (2015, summer/fall). Smoking Cessation Group. Lone Star College – Montgomery Journal of Student Writing Volume XI. Fall 2015, p. 109.
The Green Pharmacy. (2015). Retrieved from Good Reads: http://www.goodreads.com/book/show/245977.The_Green_Pharmacy
Viatcheslav Wlassoff, P. (2014, June 23). Gate Control Theory and Pain Management. Retrieved from BrainBlogger/Neuroscience and Neurology: http://brainblogger.com/2014/06/23/gate-control-theory-and-pain-management/