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Section 7
Group Cognitive Therapy for Chronic Pain

Question 7 | Answer Booklet | Table of Contents

Group therapy approaches have emerged as a common modality for administering cognitive-behavioral treatments (CBT) for chronic pain. Controlled research has established its efficacy for patients who have a variety of chronic pain problems, including low back pain, facial pain, arthritis (Keefe, Beaupre, & Gil, 2002), and headache (James, Thorn, &Williams, 1993). Surprisingly, there are few studies that have directly compared the efficacy of group versus individual treatments for chronic pain. In the few available comparison studies, there is a consistent lack of difference in treatment outcome between individually administered and group-administered CBT for pain (Frettloh & Kroner- Herwig, 1999; Johnson & Thorn, 1989; Spence, 1989, 1991; Turner-Stokes et al., 2003). Considering practitioner time and patient expense, group treatment is more cost effective than individual therapy—a distinct practical advantage that may be attractive to the busy practitioner as well as to the individual client.

In this article, we present the rationale for group CBT, illustrating with an example of group therapy focusing on the cognitive components of CBT for chronic pain. A cognitive model of pain is used as the framework for the therapy.

As is common to all psychotherapies, CBT for chronic pain requires knowledge regarding the principles of psychotherapy and knowledge regarding personality and psychopathology. Many CBT approaches are manualized, to facilitate administration of the content of the material, but manuals do not often provide information on process such as understanding the client’s nonverbal as well as verbal behaviors, the dynamic nature of the relationship between the client and the therapist, and the timing of the methods based on moment-by-moment developments within the session.

Group therapy for chronic pain has the important added dimension of group process— the interactions among the group members. The effective utilization of the group process can enhance treatment effectiveness and patient satisfaction in cognitive-behavioral treatments for chronic pain. For example, group interactions are useful for modeling appropriate response to a patient who is exhibiting pain behaviors and associated negative affect. Group treatment also serves an instructional purpose by providing the clinician with multiple related examples to choose among for discussion, thus increasing the likelihood that patients will understand the point and implement it in their lives. Individuals struggling with chronic pain often feel isolated and misunderstood; thus, group formats fulfill a supportive function by allowing disclosure of thoughts and feelings to others who have shared similar circumstances, lending a greater sense of legitimacy to the client. At the same time, when a skillful practitioner uses the group process to move clients beyond mutual empathy and toward regaining of function, a crucial component of the psychosocial treatment for chronic pain is served.

Patient Considerations
Patients who have chronic pain are often depressed and anxious, and many chronic pain conditions involve physiological comorbidities, such as degenerative diseases. These concomitant problems do not make group treatment inappropriate—in fact, many groups have been formed around a core pain problem, such as headache. Obviously, if a patient has strong preferences for individual treatment or if her schedule prohibits involvement at a prescribed group time, individual therapy will maximize treatment participation and completion. If a patient has a history of chronic interpersonal problems that would likely be disruptive to the group, individual therapy would be a better option. Finally, patients who are moderately to severely cognitively impaired are likely to gain more from individual treatment, in which pace and technique can be adjusted as necessary. These caveats aside, for almost anyone who would be eligible to participate in individual CBT for pain management group treatment is appropriate.

Group size and composition are also important patient characteristic considerations. Ideally, a group would comprise between five to seven patients; we favor limiting the size to five because it is sufficient to facilitate interaction among group members while providing enough time for each patient to be heard. With the possible exception of inpatient settings for injured workers or Veterans Administration groups, most CBT groups have more women than men because women have more chronic pain problems, seek pain treatment more frequently than men, and may be more receptive to group therapy because of a tendency to cope via communal support processes (Lyons, Mikelson, Sullivan, & Coyne, 1998; Unruh, 1996).

Although differences in patient age, ethnicity, and cultural background might cause group members to feel less connected with one another, chronic pain seems to be a unifying factor, making other potentially divisive issues less important. For example, we led a recent headache management group composed of four women, three of whom were African American (one 78-year-old who had an eighth-grade education, one 55-year-old social worker, and one 30-year-old elementary school teacher), and one of whom was a White 18-year-old university student. Our supposition was that the youngest group member would drop out prematurely because of the differences in group characteristics, but all group members completed treatment and reported value in the group interactions as part of learning to cope with pain. In reality, constraints imposed in creating a group of individuals who are willing to engage in CBT and who can receive treatment at the same time necessitate great flexibility in terms of creating the "ideal" group mix. Realistically, clients ready for group treatment do not have discrete pain disorders, in the same age cohort, with similar cultural backgrounds and socioeconomic levels. Unless the client is likely to interfere with group process or is unable to keep up with the group, we err on the side of including the person even if we have questions about potential optimal utilization
of the treatment.

Targeted Cognitive Intervention for Chronic Pain
The theoretical foundation for the treatment components described in this article is based on Beck’s (1976) cognitive model, which promotes the idea that thoughts influence feelings, behaviors, and physiological responses. Cognitive therapy (CT) is frequently utilized to treat a variety of biopsychosocial problems and has recently been applied to pain management (e.g., Thorn, 2004; Winterowd, Beck, & Gruener, 2003). There is substantial overlap in CBT and CT techniques; the difference between the two is based on the cognitive conceptualization of the case and treatment planning in CT. Some cognitive-behavioral techniques, such as self-regulatory treatments (e.g., biofeedback, relaxation), do not emphasize a focus on cognitions or beliefs and thus would not be considered cognitive approaches (Beck, 2001). Nonetheless, there is considerable empirical support for certain self-regulatory treatments in pain management, and thus they are often included in a CBT regimen (Hoffman, Papas, Chatkoff, & Kerns, in press). Our article highlights the cognitive components of treatment to improve their integration into CBT for pain, and to illustrate their utilization in group treatment.

The structural foundation of CT for chronic pain is an adaptation of Lazarus and Folkman’s (1984) transactional model of stress. According to the stress-appraisal-coping model of pain patients’ cognitions predict their adjustment to chronic pain through their appraisal of the pain and related stressors, their beliefs about their ability to exert control over pain, and their choice of coping options (Thorn, 2004). A number of important treatment principles come into play in treating chronic pain patients with a CT approach. These principles are presented in Table 1, which summarizes the cognitive model of pain. The research foundation for this program also suggests that cognitive variables are a critical component in successful CBT for chronic pain (see Thorn, 2004, for a review of the relevant literature). In particular, negative pain-related cognitions, particularly catastrophizing, are robust predictors of pain, disability, and adaptation to chronic painful conditions, over and above other factors, such as disease, pain intensity, depression, anxiety, fear of pain, and neuroticism (Sullivan et al., 2001).

Table 1
Summary of the Cognitive Model of Pain
Individual variables: Cognitions are partly shaped by these individual considerations.
• Biological factors: Physical pathology/disease state is not a good predictor of patient adaptation to chronic pain but provides information about patient’s history of biomedical treatments.
• Personality factors: Temperamental characteristics (e.g., neuroticism, negative affectivity, emotional vulnerability) increase the risk of disability.
• Social roles: Gender roles and cultural expectations influence pain-related beliefs and choice of coping options.
• Core beliefs: Deeply held beliefs about the self as a person in pain may evolve over the course of illness but are grounded in early formulations about the self. Primary appraisals: Initial judgments regarding pain, potential pain, and related environmental demands shape secondary appraisals and selection of potential coping options.
• Threat: The perception that danger outweighs coping ability affects appraisals.
• Harm/loss: The perception that damage has occurred/resulted from stimulus influences judgments.
• Challenge: The perception that ability to cope is not outweighed by potential danger influences appraisals. Secondary appraisals: These range from spontaneous situation-specific cognitions to deeply held convictions and can elicit emotional responses and influence coping.
• Automatic thoughts/cognitive errors: Frequently occurring, situation-driven thoughts can occur without conscious awareness (e.g., catastrophizing, negative sense of self, negative interpretation of interaction with others, and self-blame).
• Intermediate beliefs: Acquired attitudes arise from personal, cultural, and environmental factors (e.g., beliefs about the cause and appropriate treatment for pain and beliefs about one’s control over pain). Cognitive coping: Thoughts, or thought techniques, are used in an attempt to mitigate the stress associated with chronic pain.
• They encourage cognitive, affective, and behavioral attempts to manage pain and associated environmental demands.
• They may or may not be related to mastery or adaptive outcome.
- Thorn, Beverly & Melissa Kuhajda; Group cognitive therapy for chronic pain; Journal of Clinical Psychology; Nov 2006; Vol. 62; Issue 11.

Personal Reflection Exercise #2
The preceding section contained information about group cognitive therapy for chronic pain.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Examining the Association between Group Context
Effects and Individual Outcomes in an Interdisciplinary
Group-Based Treatment for Chronic Pain Based
on Acceptance and Commitment Therapy

Gilpin, H. R., Ratanachatchuchai, S., Novelli, D., McCracken, L. M., & Scott, W. (2022). Examining the association between group context effects and individual outcomes in an interdisciplinary group-based treatment for chronic pain based on acceptance and commitment therapy. British journal of pain, 16(4), 420–432.

Peer-Reviewed Journal Article References:
Harmon-Jones, C., Hinton, E., Tien, J., Summerell, E., & Bastian, B. (2019). Pain offset reduces rumination in response to evoked anger and sadness. Journal of Personality and Social Psychology, 117(6), 1189–1202.

Noyman-Veksler, G., Shalev, H., Brill, S., Rudich, Z., & Shahar, G. (2018). Chronic pain under missile attacks: Role of pain catastrophizing, media, and stress-related exposure. Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 463–469.

Rogers, A. H., Gallagher, M. W., Garey, L., Ditre, J. W., Williams, M. W., & Zvolensky, M. J. (2020). Pain Anxiety Symptoms Scale–20: An empirical evaluation of measurement invariance across race/ethnicity, sex, and pain. Psychological Assessment, 32(9), 818–828.

QUESTION 7
What does a clinician need to effectively utilize during group therapy in order to enhance treatment effectiveness and patient satisfaction in cognitive-behavioral treatment for chronic pain? To select and enter your answer go to Answer Booklet.