Abstract
PURPOSE
Social support is associated with improved outcomes for people with chronic pain and is an important but understudied component of biopsychosocial pain care. We sought to explore how group medical visits facilitate 4 distinct types of social support—emotional, appraisal, informational, and instrumental—among primary care patients with chronic pain.
METHODS
We collected qualitative data within a randomized trial of integrative group medical visits for chronic pain, focusing on 2 cohorts of English-speaking patients randomized to group medical visits. Data came from 16 observed group medical visits, 2 focus groups, and 12 semistructured interviews. The group medical visit intervention entailed 12 weekly sessions combining clinical care, pain education, mindfulness meditation, therapeutic movement, and facilitated discussion. We analyzed data using team-based flexible coding and codebook thematic analysis.
RESULTS
The 26 participating patients were predominantly low-income (80.8% had an annual household income of less than $50,000); 50.0% identified as Black or African American, 15.4% as Hispanic or Latine, and 23.1% as White. On average, they had severe pain with a mean intensity rating of 7.7 out of 10. All 4 social support types emerged through structured program components (curriculum, facilitation strategies, program structure) and interactions among peers and facilitators. Emotional support fostered belonging and countered isolation and stigma. Appraisal support normalized struggles and fostered self-compassion. Informational support combined interactive education with peer-to-peer knowledge exchange. Instrumental support provided concrete assistance.
CONCLUSIONS
Our findings illustrate how group medical visits for chronic pain mobilize 4 interwoven and reinforcing forms of social support as core therapeutic processes. They also highlight group medical visits as a potential model for biopsychosocial chronic pain management among primary care patients.
Key words: chronic pain, pain management, group medical visits, office visits, social support, peer group, delivery of care, practice-based research, biopsychosocial model, safety-net providers, vulnerable populations, primary care
INTRODUCTION
Chronic pain affects more than 1 in 5 adults in the United States.1 The biopsychosocial model of pain conceptualizes chronic pain as having interrelated causes and manifestations at the individual, interpersonal, community, and organizational levels.2 Beyond its biologic and psychological dimensions, chronic pain is deeply shaped by social context.3 Chronic pain–related stigma and social isolation can increase pain, disability, opioid use, and mortality.4-6 The effects of social factors are especially pronounced for structurally vulnerable patients—including individuals with low socioeconomic status, and racially and ethnically minoritized populations—who experience disproportionately high rates of chronic pain and persistent disparities in diagnosis and treatment.1,7-10 Conversely, social support—the experience of being cared for, valued, and connected—improves coping, reduces depression, and enhances quality of life for people with chronic pain.11-13 Social support needs are challenging to address in primary care because of time constraints, demands on resource allocation, and structural barriers.14-16 Yet primary care remains the most common site for pain management and a critical setting for implementing biopsychosocial care.17,18
Group medical visits are a promising model to address social aspects of biopsychosocial pain care. These visits expand access to multimodal care by allowing multiple patients with a common condition to receive billable medical care, health education, and mutual social support. Community health centers have successfully implemented group medical visits.19,20 Previous studies have demonstrated that group medical visits improve pain outcomes and quality of life while fostering a sense of belonging and community.21-25 Few studies have systematically examined how group medical visits enact different forms of social support and how this support contributes to observed improvements.
In this study, we applied the social support typology of House,26 which distinguishes 4 distinct types of social support that shape how people cope with stress, thereby influencing health: emotional (expressing care and empathy), appraisal (providing feedback or validation), informational (sharing knowledge or advice), and instrumental (offering tangible help or resources). This framework has been widely used in health research and applied to group medical visits for diabetes and prenatal care.27,28 To our knowledge, it has not been applied to group medical visits for chronic pain, despite the centrality of social support in managing pain. We examined how patients experienced social support in group medical visits for chronic pain at a community health center. We sought to clarify how these visits can leverage social support as an active mechanism of benefit for biopsychosocial pain management.
METHODS
Study Design
We analyzed descriptive and qualitative data from a larger, mixed-methods randomized trial that evaluated group-based pain management in primary care clinics in the San Francisco Health Network.21 Participants were patients aged 18 years or older, fluent in English or Spanish, and empaneled to one of the network’s primary care practitioners, and had chronic pain present for at least 3 months. The trial used a 2×2 factorial design in which half of patients were randomized to group medical visits. We report on a subsample of English-speaking patients randomized to group medical visits. The University of California San Francisco Institutional Review Board approved all study procedures (No. 22-37078). Patient consent was obtained at trial enrollment.
Group Medical Visits
Each group medical visit cohort was offered 12 weekly visits held in a conference room at a primary care clinic. The average number of attendees was 7 per group. The facilitator team included 1 or 2 primary care and behavioral health clinicians providing billable care, and a movement and meditation instructor. The visits were led by 2 or 3 co-facilitators having different genders and racial/ethnic identities to model inclusive representation. Space and basic staffing were provided by the San Francisco Health Network; food, supplies, and additional staffing were provided through the grant-funded research.
Each 2-hour visit combined clinical care, pain education, mindfulness meditation, gentle movement instruction, and facilitated discussion. Specific topics varied by week (Table 1). Facilitators used strategies for inclusion, safety, and connection, such as creating group agreements, setting norms of confidentiality, and listening respectfully. Facilitators invited patients to share their pain stories in the first 2 visits; each visit included time for informal connection while eating and during facilitated discussion.
Table 1.
Topics of the Group Medical Visits by Week
| Week | Topicsa |
|---|---|
| 1 | Understanding pain and pain management |
| 2 | Pain stories, treatments, and self-care |
| 3 | Mindfulness workshop (cultivating positive emotions through loving kindness and self-compassion) |
| 4 | Thoughts, feelings, emotions, and pain; stigma |
| 5 | Physical movement workshop |
| 6 | Medication education |
| 7 | Nutrition workshop |
| 8 | Pacing, physical movement |
| 9 | Stress management |
| 10 | Navigating relationships, communicating about chronic pain |
| 11 | Sleep and pain |
| 12 | Review of core concepts, moving forward |
Every visit included 4 core components: psychoeducation, mindful movement, skills practice, and peer support through facilitated discussion.
Notes: Table adapted from Chao et al,21 licensed under Creative Commons Attribution-Non-Commercial 4.0 License. Patients graduated after week 12.
Data Collection
Trained researchers observed patients during the group medical visits using structured field notes, focusing on peer and facilitator relationships and discussions related to social isolation, stigma, and social support. All patients randomized to group medical visits were invited to participate in focus groups and semistructured interviews conducted after completing the 12-week intervention. The study team developed focus group and interview guides based on study aims and prior group medical visit research (Supplemental Appendix). We collected demographics and patient-reported pain measures at baseline. Patients received gift card incentives for data collection.
Data Analysis
We analyzed data using established qualitative methods for large, team-based studies: flexible coding and codebook thematic analysis.29,30 Analysis included all available qualitative data from the 2 initial English-language group medical visit cohorts, including 16 observed group medical visits, 2 focus groups (16 patients total), and 12 semistructured interviews. Focus groups and interviews were audio recorded and professionally transcribed. Transcripts, field notes, and demographic data were uploaded into Dedoose version 10.0.59 (SocioCultural Research Consultants, LLC). We selected pseudonyms to deidentify, but not depersonalize, patients.
In the first stage of analysis, the research team collaboratively developed a codebook using both inductive and deductive codes by reviewing study materials and qualitative data. Transcripts and field notes were index-coded by 5 trained qualitative researchers (including co-authors H.J.K., J.L.N.J., A.T-L.); differences in coding were discussed among authors and used to refine code definitions. In the second stage of analysis, the first author (H.J.K.) conducted a focused analysis of data excerpts related to social support (using codes including “social support” and “relationships and pain”). Through collaborative analytic memo writing and team discussions, it became clear that all 4 types of social support (emotional, appraisal, informational, and instrumental) were present in the data. The first author coded all social support–related data using these types.
Positionality
The author team includes researchers and clinicians from the larger study team. We intentionally created a team with diversity in personal and professional experiences, including gender identity, racial and ethnic identity, experiences with chronic pain, career stage, and training discipline (medicine, nursing, public health, and sociology). Data collection and analysis were conducted by researchers with a range of personal and professional backgrounds (eg, racial and ethnic identities, including Asian, Black, Latine, and White), all of whom had qualitative training and involvement in multiple aspects of the study.
RESULTS
Patient Characteristics
A total of 26 patients participated in the study. Table 2 shows their aggregate characteristics and Table 3 shows the individual characteristics of the subset quoted in this article. All had public insurance; 80.8% had a household income of less than $50,000 per year; 50.0% identified as Black or African American, 15.4% as Hispanic or Latine, and 23.1% as White. On average, the patients had severe pain at baseline, with a mean pain intensity rating of 7.7 out of 10.
Table 2.
Baseline Characteristics of Study Patients (N = 26)
| Characteristic | Value |
|---|---|
| Age, mean (SD), y | 58.2 (12.0) |
| Gender identity, No. (%) | |
| Female | 15 (57.7) |
| Male | 8 (30.8) |
| Transgender, genderqueer | 3 (11.5) |
| Race and/or ethnicity, No. (%) | |
| Black or African American | 13 (50.0) |
| Hispanic or Latine | 4 (15.4) |
| White | 6 (23.1) |
| Other or more than one race | 2 (7.7) |
| Unknown | 1 (3.8) |
| Educational level, No. (%) | |
| Some high school or less | 5 (19.2) |
| High school graduate | 12 (46.2) |
| Some college or more | 9 (34.6) |
| Employment status, No. (%) | |
| Employed (full- or part-time) | 8 (30.8) |
| Not employed | 18 (69.2) |
| Relationship status, No. (%) | |
| Divorced | 6 (23.1) |
| Married or living with domestic partner | 3 (11.5) |
| Never married | 12 (46.2) |
| Widowed | 5 (19.2) |
| Annual household income, No. (%) | |
| < $10,000 | 9 (34.6) |
| $10,000-$24,999 | 9 (34.6) |
| $25,000-$49,999 | 3 (11.5) |
| ≥$50,000 | 2 (7.7) |
| Prefer not to answer | 3 (11.5) |
| Average pain intensity rating, mean (SD)a | 7.7 ± 1.7 |
| Pain duration, mean (SD), y | 11.4 ± 9.1 |
On a scale from 0 (no pain) to 10 (worst pain imaginable).
Table 3.
Characteristics of Quoted Patients, Alphabetized by Pseudonym
| Pseudonym | Characteristics |
|---|---|
| Alden | Aged 53, male, White, pain duration of 15 years |
| Angela | Aged 65, female, multiracial, pain duration of 9 years |
| Cherry | Aged 59, female, multiracial, pain duration of 6 years |
| Ms Driver | Aged 43, female, Latine, pain duration of 4 years |
| Fidel | Aged 53, male, White, pain duration of 15 years |
| Lee | Aged 28, transgender, White, pain duration of 5 years |
| Marsha | Aged 57, female, Black, pain duration of 4 years |
| Mr Pace | Aged 51, male, Latine, pain duration of 1 year |
| Patience | Aged 80, female, Black, pain duration of 5 years |
| Patty | Aged 64, female, White, unstated pain duration |
| Rose | Aged 69, female, Black, pain duration of 20 years |
| Safe | Aged 52, transgender woman, pain duration of 23 years |
| Sage | Aged 72, female, Black, pain duration of 43 years |
| Serena | Aged 41, female, Latine, pain duration of 18 years |
| Mrs Waters | Aged 62, female, White, pain duration of 15 years |
Types of Social Support
We identified all 4 types of social support within the group medical visits for chronic pain. Emotional, appraisal, informational, and instrumental support were cultivated through structured program components (curriculum, facilitation strategies, program structure) and unstructured interactions among peers and facilitators (Table 4). We describe the findings in detail below.
Table 4.
Examples of Social Support in Integrative Group Medical Visits by Type and Source
| Type of social support | Source of social support | |
|---|---|---|
| Facilitator | Peer | |
| Emotional | Group norms of confidentiality, welcoming patients who arrive late, no punishments for absences, permission to listen rather than speak, and sharing from personal experience Checking in individually with upset or grieving patients Creating space to discuss the intersectionality of pain with marginalized identities and systems of oppression, including bias in health care regarding chronic pain |
Attentive listening providing verbal and nonverbal affirmations Physical gestures (hand on shoulder or a hug), and texting one another to check in after a difficult visit Commiserating and bonding over shared identities and challenges, including being on public insurance and experiences of xenophobia, ableism, and anti-Black racism |
| Emotional/appraisal | Writing out individual appreciations and reflections on progress and growth for each patient during graduation Celebrating small wins (meditating 2 days last week, sleeping an hour more each night) |
Sharing words of comfort or spontaneous appreciations for one another (“I love you, you’re a lifelong teacher and you inspire me” – Rose) Providing affirmations that challenge negative self-talk and promoting self-compassionate reframing (“It’s okay that you haven’t done it yet, I know you’ll do it when you’re ready” – Marsha) |
| Appraisal | Sharing their own life experiences and setbacks and actively soliciting patients’ stories Setting realistic goals and expectations for change (“Five out of 7 days using the sleep hygiene tools is amazing! Habits are hard to develop and none of us will get it perfectly at first.”) Offering a supportive environment for tracking progress, including pacing and rest, highlighting progress, and reminding people of their strengths |
Listening to others’ setbacks and challenges with chronic pain and normalizing their own struggles Sharing successful coping mechanisms and strategies for managing pain |
| Informational | Fostering active learning by encouraging patients to ask questions, share their own experiences, and adapt curricular material to their individual circumstances and needs Explaining concepts in plain language and accessible metaphors (“neurons that fire together wire together,” central sensitization as ruts in a dirt road), with customized education handouts Offering modifications for movements and exercises based on physical limitations Sharing knowledge about navigating the health care system, accessing community resources, or finding reliable online health information Providing patients with food at all visits, as well as equipment for exercise (yoga balls, straps), sleep (ear plugs, sleep masks), and nutrition (herbal teas) |
Answering one another’s questions about the visit content or study logistics Sharing creative ways of adapting to physical limitations (eg, teaching grandchildren to cook when a patient could no longer stand in the kitchen) and of using common household objects as pain-related tools (eg, frozen water bottles for plantar fasciitis) Sharing self-developed modifications for exercises for those in wheelchairs Sharing strategies for navigating health care and social services (housing navigators who are understanding of disability accommodations, clinics with knee braces in stock) |
| Instrumental | Connecting patients to resources, such as counseling and psychological support, massage therapy, and social services | Driving patients without cars to and from visits; helping each other transfer between chairs and wheelchairs; cooking food for the group Providing culturally rooted herbal and nutrition remedies for sleep and pain and information on where to purchase these ingredients with electronic benefits transfer (EBT) |
Emotional Support: Cultivating Safety and Belonging
Patients described how chronic pain had eroded their social lives and left them feeling isolated, misunderstood, or judged, even by those closest to them. Many expressed that people without chronic pain could not understand them and that they had to carry their struggles alone. Emotional support in the group medical visits disrupted isolation by creating a nonjudgmental space where patients connected with others with shared experiences (Table 5). Most patients experienced combinations of socioeconomic stress, racism, xenophobia, and other forms of oppression. Group discussions validated their experiences of marginalization, bias, and injustice, including their relationship to pain.
Table 5.
Quotes Exemplifying the Types of Social Support
| Type of support | Quote and patient |
|---|---|
| Emotional support: expressions of empathy, love, trust, and care that provide a sense of being valued and understood | “There was times that I honestly wanted to commit suicide. I wanted to give up. I’m a very social person, but that all changed. [With] a cane in my hand, I couldn’t do the things I was doing [before], and I was miserable… Listening to other people [in the group] that have similar sufferings made me realize there’s a lot of people out there that are going through very much the same thing with similar side effects or results, affecting their marriage or just their livelihood or whatnot. I realized I’m not alone, and that was the most positive aspect of the study.” – Angela |
| “[The group medical visit] made all the difference in my social life as well as me being understood… I found that there were people that they were just like me. They were suffering, some with the same thing, and they had the same exact emotions, feelings, disappointments, hope, same exact feelings, same things, but we’re experiencing it alone. That’s where the difference is. If you have someone that understands what you’re going through, you can make it.” – Sage | |
| “[A group participant] lost her son to gun violence. I felt like everyone did a real good job of listening and providing support to her when she was telling her story. And similar stories for other people. It made me feel very good to be in a space that was supportive in that way.” – Lee | |
| “This is what makes this program important and especially they make people together and everybody is sharing the same pain. Some people are more in pain than you, but we are all in the same emotional wave. And this makes you feel good that you are not alone and there are people professionally trying to help you and this is very comforting.” – Alden | |
| Appraisal support: affirmation, feedback, and social comparison that help individuals evaluate themselves and their situations | “Being in the group removed shame from my mental plate. Shame is such a destructive, unnecessary thing to feel, and people who have chronic pain feel shame unnecessarily. Just going there once a week and talking to all these people in pain who are as kooky as I am just removed all of that.” – Mrs Waters |
| “Coming into this group and meeting these new people in my life, I started learning about people with disabilities still dancing or still doing art. I went to events in the city … and I was like, oh my god, this person in this wheelchair is dancing so fierce. Or these people have fibromyalgia and they’re in extreme pain, but they’re still so graceful. If it wasn’t for this group, a lot of things in my life in the last few months wouldn’t be in existence. It’s like this group, we all willed things for each other and I’m seeing it. … we’re all different than the first day we met.” – Ms Driver | |
| “Having the group took the pressure off compared to one-on-one therapy, personally. You have other people to look at. And it was also nice to hear other people’s thoughts and then just what they’re going through and wanting to grow from there or not get worse. … I like to encourage people, and I like to be encouraged.” – Cherry | |
| Informational support: advice, guidance, and knowledge that aid problem-solving and decision making | “When I start feeling scared about…falling back into the trap of being immobile in bed again, I say to myself: Remember what they taught you. If I think of the things [the facilitator] says about breathing and focus and going to your safe place, I can calm myself down, jump myself out of that hole, and put the dirt back so that I don’t fall in.” – Ms Driver |
| “The things that we did together were very therapeutic … you didn’t make us feel like guinea pigs, because you were absorbing things that we were saying and trying to figure out the things that we needed and the order in which they should be done. And so things weren’t set in stone. You were able to work around this or manipulate the situation according to need. And that really made a difference. It showed you cared.” – Sage | |
| “The techniques you guys taught us has changed my day-to-day. I have made changes at home. I feel more relaxed being at home now… I was just dealing alone with the pain at home and more loneliness. Now it’s like I feel good being alone with all … the new things that I’ve learned in this program. I’m adapting it, and I feel good when I’m doing it in the house, the little stretches, the meditation and all the other things that we learned like nutrition and how to handle the pain, what to do … I don’t feel that miserable now.” – Marsha | |
| Instrumental support: tangible aid and services that directly assist with practical needs and tasks | “The first time I did the qigong tai chi type exercise, I tried so hard because I’m a people pleaser and later I was like why did I do that? I’m in so much pain … but then I told [the facilitator] and she was great. I felt very supported in [modifying or doing different movements] or just sitting down.” – Mrs Waters |
| “I would take a few [group members] at a time… And since some of them could only be in the car sitting for 2 hours or couldn’t walk, I found benches by the water a few steps from the car … that’s one way I healed myself, my girl-friend would take me on rides. Now I take the others as my appreciation to really lifesaving moments.” – Ms Driver |
Facilitators established a welcoming environment through intentional choices and statements, such as “Your story might help someone else feel less alone” (Facilitator 1). One patient described the experience of hearing everyone else’s stories: “People cried. We all felt strong sadness, empathy, and love for one another, and it made it easier to talk openly knowing that everyone else also has pain” (Cherry, focus group; for descriptors of quoted patients, see Table 3). The group medical visit’s inclusivity—ensuring that no one was shamed for arriving late, missing sessions, or choosing not to speak—enabled patients to show up as they were and created “a space of unconditional acceptance” (Rose, interview), “a refuge” (Sage, group observation), which was “like coming home” (Serena, interview).
As trust deepened, patients disclosed difficult emotions, including fear and grief. Peers and facilitators responded with attentive listening, validation, and gestures of care, cultivating a “life-changing and healing” (Ms Driver, interview) sense of mutual recognition. Grief and loss were recurring themes, as multiple patients lost loved ones to violence or illness during the program. The group provided comfort and reassurance and held space for mourning, “creating open spaces for grief and buried emotions to flow into” (Safe, interview). A patient who lost a close family member to gun violence said, “Through this group, I got the chance to express a lot of myself, which helped me a lot, instead of doing nothing at home grieving by myself” (Patience, group observation). During a single week, 4 patients lost family members, and a facilitator checked in with each individually. One patient described this action as genuine care that contrasted with other research: “It didn’t feel like being a guinea pig” (Ms Driver, focus group).
Appraisal Support: Validation and Reframing
Appraisal support in the group medical visits allowed patients to make meaning of their pain. Sharing openly about similar challenges normalized their struggles, reduced shame, and fostered self-compassion. Facilitators contributed to this process by disclosing their own challenges and adaptive strategies, modeling personal vulnerability uncommon in other health care settings. Patient Marsha described a facilitator’s story about finding joy in an electric bike after knee pain ended her lifelong hobby of cycling. This prompted Marsha to “pause and breathe and remind myself of how there was no point in clinging to old expectations, and my body [is] still amazing” (group observation).
Seeing peers implement pain management strategies and embrace joy, movement, and new opportunities expanded patients’ sense of what was possible. One told the group, “I’ve learned so much from all of you—your resilience makes me not give up on myself. No matter how hard it gets, I know I can push another day” (Ms Driver, group observation). Patients valued the group’s diversity in ages, backgrounds, and personalities, finding that “alternative ways of thinking about things is helpful because there’s different ways to manage problems” (Safe, focus group).
Peers and facilitators nurtured hope by challenging negative self-talk and encouraging positive reframing. This helped patients shift their focus from perceived failures to building self-efficacy. One patient lamented her inability to complete goals, such as using sleep hygiene techniques daily. Facilitator 2 reminded her that sleeping better 5 out of 7 days was an accomplishment and that “habits are hard to develop—none of us get it perfectly at first.” The patient thanked the facilitator for “bringing in self-compassion, because I’m so very hard on myself and my mistakes, and worries keep me up constantly” (Patty, group observation). This cycle of recognition, encouragement, and reframing helped patients see themselves as capable, which increased their motivation to engage with strategies.
Informational Support: Practical Knowledge and Skills
Both the structured curriculum and unstructured peer-to-peer knowledge exchange provided informational support. Patients appreciated the group format, extended time, and responsiveness of the facilitators, noting the contrast with the rushed, clinician-directed style of typical primary care. One patient stated, “It’s overwhelming to try and understand what the doctors are saying. You get 5 minutes and then they’re already walking out the door” (Mr Pace, focus group). Facilitators tailored content and delivery to patients’ needs, asking each cohort which topics most interested them. They encouraged patients to experiment with tools, such as gentle movement, breathing techniques, and stress reduction practices, to fit their own bodies and circumstances. Patients learned to take ownership of knowledge and reshape it to serve them, cultivating agency and capability.
Knowledge exchange among peers was equally important. Peers shared strategies for navigating health care and social services and managing pain-related limitations. Peer-to-peer sharing based on lived experience provided practical, daily adaptations to manage chronic pain. Patients were considered valued contributors to collective learning with expertise grounded in their own lives.
Instrumental Support: Tangible Acts of Care
Instrumental support was expressed through tangible aid that enabled patients to manage compounding challenges. For patients, living with chronic pain was exacerbated by financial strain that limited access to resources and care. Facilitators connected patients to free resources, such as counseling, massage therapy, and social services; peers offered rides or helped with mobility needs during visits. These gestures addressed immediate barriers to care, making the program accessible to individuals who might otherwise have been excluded.
For patients facing urgent needs, facilitators and peers identified immediate solutions. One patient received a call that her daughter was in the emergency department but could not reach her and “had no idea what to do next, everything felt so helter-skelter” (Patience, group observation). The facilitator used his knowledge and resources as a clinician to locate the hospital, and another patient called the hospital to inquire about her daughter. Patience expressed gratitude and relief that others cared enough to “share the cognitive and emotional load rather than having to solve this problem by myself.”
Instrumental support included tangible acts of care. One patient drove small groups from her cohort to the coast, carefully accommodating each person’s physical limitations. Accessibility was the difference between exclusion and meaningful participation in a healing experience often out of reach for those with chronic pain. Patients interpreted these acts of care as evidence that their struggles mattered to others, which strengthened trust and belonging within the group.
DISCUSSION
Our findings illustrate how group medical visits for chronic pain mobilized multiple, interwoven forms of social support as a central driver of patient outcomes, enacted through structured facilitation and peer interaction. Safety and trust cultivated by emotional support allowed patients to share openly. These vulnerable disclosures enabled appraisal support through normalization of shared experiences. Appraisal support challenged negative self-talk, and seeing peers successfully implement coping strategies fostered motivation. Informational support broadened patients’ coping repertoire and deepened their capacity to manage pain. Instrumental support addressed practical barriers to care through tangible assistance and resource sharing. These forms of support reinforced one another: emotional safety facilitated knowledge exchange and help seeking; practical assistance strengthened trust, belonging, and self-management. Our findings align with previous research showing that multimodal support networks confer greater health benefits than single forms of support.31,32
Pathways by Which Social Support May Address Chronic Pain
Chronic pain is often entangled with stigma—enacted, internalized, and structural—which can exacerbate distress, reduce access to health resources, discourage help seeking, and contribute to social isolation.4,33 Our study patients experienced intersectional stigma—the interaction of multiple stigmatized identities or conditions (eg, pain, disability, race, poverty). Intersectional stigma creates barriers to health care access, worsens stress and mental health, and undermines treatment adherence.34 In the group medical visit, emotional support disrupted stigma by normalizing shared experiences, reducing feelings of defectiveness, and counteracting shame through reciprocal, caring connections. Appraisal support helped patients positively reframe their pain experiences and cultivate self-understanding. These cognitive shifts are recognized as key to interrupting pain catastrophizing, the persistent negative cycle of self-blame and fear associated with greater pain, disability, and psychological distress.35 Witnessing their peers and celebrating meaningful progress bolstered patients’ pain self-efficacy, which predicts greater engagement with self-management strategies and improved pain outcomes.36 These findings augment prior findings showing that a high level of perceived social support is linked to lower pain catastrophizing and higher self-efficacy in people with chronic pain.37,38
Informational support reinforced pain self-efficacy by equipping patients with knowledge and tools. Our findings align with those of previous studies showing that peer support may uniquely strengthen adherence to coping strategies, increasing self-efficacy and reducing pain-related distress.39 Instrumental support facilitated access to care, sustained group medical visit participation, and provided practical assistance during crises. Practical coping assistance may lessen pain by reducing the physical and psychological consequences of acute stressors.40
Together, these processes illuminate why group medical visits may be particularly effective for chronic pain. Group medical visits address stigma and isolation, reduce pain catastrophizing, build self-efficacy, promote self-management, and attenuate pain-amplifying stressors and barriers to care.
Advancing Chronic Pain Management Through Collective Care
The group medical visit provided nonpharmacologic pain care in a community health center while creating a space in which patients’ experiences of structural inequity were acknowledged, validated, and collectively navigated. Informational and instrumental support helped reduce barriers to care engagement for individuals facing financial strain, systemic racism, and disability. Emotional and appraisal support validated these lived experiences and countered isolation and stigma. The group medical visit structure creates an ethic of ownership; patients contribute to a community while receiving care.41
The reciprocal exchange of knowledge, validation, and tangible assistance embodies principles from mutual aid theory and disability justice, which uphold the concept that interdependence and collective care are central to well-being.42-44 Mutual aid emphasizes horizontal relationships in which all members, including chronically ill and disabled individuals, contribute and benefit, fostering solidarity without rigid hierarchies.45 Disability justice positions such reciprocal networks as a practical necessity and act of resistance against systems that isolate and devalue disabled and chronically ill people.43,44 In the group medical visit, lived expertise was as valued as clinical knowledge. Support and assistance flowed freely between peers, and the group co-created an accessible environment of collective responsibility.
Study Limitations
We included in our study only English-speaking patients in a single urban safety net network, and patient engagement varied. Patients overwhelmingly described the group medical visits as beneficial; however, in-person participation required navigating financial strain, competing caregiving responsibilities, and health-related limitations that affected attendance. Patients were included in focus groups and interviews regardless of group medical visit attendance; findings may not fully capture differences by level of engagement. The benefits of the group medical visit may be more strongly realized among those who participated consistently. Finally, we did not assess benefits beyond 3 months, and durability of perceived changes remains unknown.
Practice Implications
Group medical visits offer a scalable model for expanding access to multimodal, biopsychosocial pain management in primary care. These visits combine billable clinical care with health education, peer support, and nonpharmacologic treatment to improve population health and patient and clinician experiences while reducing the cost of care.46,47 Organizations implementing group medical visits should prioritize social support as a core mechanism. The cultivation of trust, mutual recognition, and social connectedness was not incidental, but facilitated through intentional practices, such as trauma-informed facilitation, cultural humility, flexibility in participation, encouragement of sharing lived experiences, and responsiveness to patient needs. The impact of group medical visits depends on the degree to which they are designed to foster accessibility, relational safety, and meaningful participant contribution. Implementation factors are beyond the scope of this study but have been addressed in recent research.48 Implementation of group medical visits to promote collective care can reduce reliance on short, one-on-one encounters and foster continuity, trust, and collective agency.49
Acknowledgments:
The authors thank the many people who have contributed to the San Francisco Health Network’s Integrative Pain Management Program (IPMP), including the IPMP Steering Committee, integrative health practitioners, primary care and behavioral health clinicians, SFDPH primary care leadership; group facilitators including Sudha Prathikanti, MD and Vadan Ritter, LAc; research staff including Julia Wu, Denise Ruvalcaba, and Samuel Solis; and all the patients who have participated in the program. The authors also thank Brooke Walker, MS, MedRefine Editing Services, LLC, who provided editorial support.
Footnotes
Conflicts of interest: authors report none.
Funding support: Research reported in this publication was supported by the HEAL Initiative Advancing Health Equity in Pain Management Program, National Institute on Minority Health and Health Disparities (NIMHD), and the National Institute of Neurologic Disorders and Stroke (NINDS) of the National Institutes of Health (NIH) under Award Numbers R61MD018333 and R33MD018333. Authors received additional support for conducting research reported in this publication through NIMHD (K01MD015766, A.T-L.).
Disclaimer: The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Previous presentation: Preliminary findings of this study were presented at the International Congress on Integrative Medicine & Health; March 5, 2025; Seattle, Washington.
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