Written by Megan Bronson RN, MSN, CS on November 6, 2019
That support groups are helpful to people dealing with a broad range of life challenges, losses, and traumas is well documented. For burn survivors, finding a support group of people who understand the long journey back after a burn injury and who can therefore offer hope and direction in the process of recovery is a godsend. Support groups can decrease the sense of isolation and stigmatization that many burn survivors feel. Being a part of a support group can be the first step in reconnecting socially after burn injury. Every journey begins with a single step, and the step of finding a healthy and healing support group is often an essential one for burn survivors, their families, friends, and caregivers.
ORGANIZING A GROUP
Setting up a support group would seem a fairly simple task—find a room, set a time to meet, decide if the group will be facilitated or self-run by survivors, put out the cookies and chairs, and send out the flyers. Creating emotional safety in a support group is quite another matter and deserves specific attention.
When my daughter was a little girl she used to write recipes for me to try—my favorite was Lion Soup which she wrote at about age 4. The recipe began with “First you catch a lion.” Creating emotional safety in a support group can be like that. What sounds easy can actually be a complex process. However, this process can be broken down into a number of essential ingredients.
Of the many factors to consider in creating emotional safety in any support group, the most essential are confidentiality, the appropriate responses to feelings and the practice of unconditional presence, and a respect for boundaries. Setting the ground rules regarding these specific factors at the beginning of each support group establishes the safety for the group. It is important to briefly restate these ground rules even if the same group of people meet consistently and anytime people arrive after the ground rules have been stated.
Establishing the confidential nature of what is shared in the group is an essential ground rule for any support group. Stating clearly, “What is shared in this room, stays in this room,” and then asking the group members to commit to this boundary is the beginning of establishing group safety. It is not okay to share other people’s stories or details of their life that they might choose to reveal in a support group. Maintaining confidentiality is essential to the foundation on which the emotional safety of a support group rests.
CREATING A SAFE PLACE FOR FEELINGS
Many people were taught that some feelings are acceptable and others are not, that some feelings are negative and others are positive, and that somehow we need to be rescued from our feelings, especially painful ones such as anger, sadness, hurt, fear, hopelessness, helplessness, and guilt. Many people have had their feelings shamed in their family of origin and have anxiety about risking sharing feelings in a group. The reality is that in order to move through grief and recover from trauma, both of which often accompany burn injury, survivors need to be able to feel and release their feelings.
When the following basic principles about feelings are honored, safety for feelings can be created in a relationship or a group:
Feelings are neither right nor wrong, good nor bad. All feelings are okay and do not require either a negative or positive judgment.
Feelings are meant to be transient visitors, they are not meant to take up permanent residence in our psyche.
Telling someone they should or shouldn’t feel something does not help them, but rather causes feelings to become distorted or blocked.
Feelings can be released when they are heard with compassion, empathy, respect, and a lack of judgment. This is what unconditional presence means.
Respecting the physical, emotional, spiritual, and intellectual boundaries of members of a support group is also an essential element in creating group safety. Sometimes people have difficulty hearing the struggle, emotional pain, or seeing the tears of another without needing to rescue them. This is most often due to some unresolved issue or pain of their own. Rescuing can present in a support group as interrupting, telling people what to do about their problems, and/or physical rescuing, such as uninvited or unsolicited hugs.
Respect for spiritual boundaries requires that the group be accepting of and a safe space for diverse religious and spiritual belief systems. It is not appropriate to use the group’s time to try to convince people about any specific religion or spiritual belief. Many burn survivors share profound spiritual experiences related to their burn injury and it is, of course, appropriate to share one’s own experience if you choose to.
Telling someone what they should or should not be thinking, feeling, or doing is most often not helpful. Exceptions to this often occurs at the end of a group meeting after everyone has had a chance to share uninterrupted in the group and the group has naturally moved into a problem solving mode. At this time, sharing specific suggestions or how members have dealt with specific issues can be supportive and helpful. The key is to first allow each member a chance to share uninterrupted.
Many times survivors just need the time to share their story, harrowing as that may be, and to have that heard and witnessed. It is also important to establish that there is not an expectation that everyone share in the group—this clarification also creates safety. Whoever is facilitating the group needs to be aware of the time and keep the group on task during sharing. Occasionally, there may be someone who dominates the group’s time or who is stuck in their own story, having told it many times in the past. It is important to keep the group moving while at the same time setting limits on monopolizing behaviors in a kind and compassionate manner.
SUPPORTING THE PHASES OF RECOVERY AND HEALING
In Trauma and Recovery (1997), psychiatrist Judith Herman, MD, states that healing after trauma and traumatic loss consists of 3 elements:
Remembering and mourning
Telling one’s story
Reconnecting with life
A well-structured and well-maintained support group can support all three of these necessary phases of healing and recovery after burn trauma. Creating emotional safety is the essential foundation for a support group that truly supports recovery and healing.
Herman, Judith, Trauma and Recovery, New York: Basic Books (1997).
Megan Bronson is a psychiatric mental health clinical nurse specialist with many years of experience in working with the adult and pediatric burn survivors. She has facilitated many grief and trauma groups nationally and internationally and is a frequent presenter at the World Burn Congress, where she is also one of the facilitators of the open mic sessions.
“ The encounter with others who have undergone similar trials dissolves feelings of shame, stigma and isolation.” Irvin Yalom MD (The Theory and Practice of Group Psychotherapy)
PEER SUPPORT GROUPS
Peer Support Groups are comprised of individuals who share a common condition or circumstance such as a burn injury. These types of groups are focused on providing mentoring, emotional and social support, information, education, and practical help to each other. Those who are further along in the rehabilitation and recovery process can provide a sense of hope and direction to those more recently recovering from a burn injury. The expression of mutual caring and concern provides a powerful environment for reclaiming hope.
A peer support group may be facilitated by a non-clinical person who is a burn survivor who has been through rehabilitation and recovery from their own injury. The Peer Supporter has made adequate progress in their own recovery, been carefully screened and has had specific training, guidance and supervision in facilitating a peer led support group from a program such as SOAR (Survivors Offering Assistance in Recovery). It is essential that there be a procedure in place for ongoing clinical supervision of survivors facilitating peer led support groups by a professional with expertise in recovery after burn injury and group dynamics in order to deal effectively with problems that may arise in the group.
PROFESSIONALLY FACILITATED SUPPORT GROUPS
Facilitated Support Groups are facilitated by a professional with expertise in recovery from burn injury or a professional with mental health expertise. Whatever their professional background might be, experience and training in working with group dynamics is essential. These groups serve many of the same functions as a Peer Supported Group such as education, emotional and social support, information, and practical help. In addition facilitated groups provide assistance in working through grief, loss, and trauma issues, and focus on enhancing self esteem and social functioning. The facilitator of this type of group also has the expertise to evaluate the needs of individual group members who may require further mental health assessment, referral, and intervention beyond what the group can provide. Both types of groups require clear boundaries around issues such as confidentiality and the acceptance and non-judgment of feelings in order to establish and maintain the emotional safety of the group.
Both types of groups require mutual trust, respect and concern in order to be effective. In a facilitated group, the maintenance of group safety is the responsibility of the group facilitator, while in a peer support group this responsibility is shared by all group members. Both types of groups provide the experience of receiving as well as providing support and care to another person in similar circumstances and most importantly a forum in which one can be deeply understood by others sharing similar problems and concerns. Sharing common experiences can decrease the sense of social isolation, stigma, shame, and exclusion so often associated with a burn injury. Both types of groups can provide a safe and effective forum for beginning the process of social reentry which is so essential after burn injury.
Facilitator: Remind the group that this is a support group with the purpose of sharing, listening, learning from and being supportive of each other. A support group is not a therapy group.
Please turn off all cell phones and put pagers on vibrate.
What is shared in this group stays in this group. Ask group members for their commitment to confidentiality. If people come in late, briefly mention boundaries to them also.
All feelings are okay. Feelings are neither right nor wrong, good nor bad. We do not need to rescue people from their feelings. When feelings are heard with respect and empathy, people can begin to resolve these feelings. Remembering these things about feelings will help this group to be emotionally safe. Feelings do not need to be interpreted, analyzed, or judged.
Respect people’s physical boundaries. Ask permission to hug or touch. Listen while people are sharing.
Only one person speaks at a time--please do not interrupt or talk over others. Respect people’s opinions. Ask permission to comment on something someone else has shared or to ask them a question. It is fine to let others know that you would rather that they did not comment on what you shared.
This group is a safe space for all religious and spiritual belief systems. Please be respectful of this. It is not all right to use the group time to try to convince people about any specific religion or spiritual belief system. It is; of course, fine to share how your belief system may have been supportive and helpful to you.
Facilitator: Close the group process--thank people for attending, sharing and listening to each other. Remind the group of commitment to confidentiality.