Mike Osborn

Pain as an assault on the self: An interpretative phenomenological analysis of the psychological impact of chronic benign low back pain

This paper presents an in-depth, idiographic study illustrating how chronic benign low back pain may have a serious debilitating impact on the sufferers sense of self. Semi-structured interviews were conducted with six patients and the resultant transcripts subjected to interpretative phenomenological analysis. The analysis points to the powerful ways in which chronic pain has negative impact on patients’ self and identity. This impact is made worse in the public arena. Some of the participants describe how the ensuing derogatory self image also seems to lead to their directing negative affect towards other people. The results section gives a detailed account of these processes at work. The results are then considered in relation to relevant constructs in the extant literature, including work on illness and identity, shame and acceptance.

Being a parent of the adolescent with complex chronic pain: An interpretative phenomenological analysis

Background Previous quantitative research has shown that parents of adolescents with chronic pain report elevated levels of emotional distress in addition to limitations in social and family functioning.

It's not fair: An Interpretative Phenomenological Analysis of discourses of justice and fairness in chronic pain

Quantitative research suggests that perceiving injustice can impact negatively upon physical and psychological health in chronic pain. However, little is known about the experience and perceptions of injustice in this context. This study examines the phenomenology of justice and injustice in chronic pain. Fifteen chronic pain sufferers recruited from General Practices in upper, middle and lower socioeconomic areas participated in one of three focus group discussions. Semi-structured interviews were conducted to interrogate justice-related conceptions. All discussions were observed, audio-recorded, transcribed verbatim and subjected to Interpretative Phenomenological Analysis. The dominant theme of the upper socioeconomic group was ‘seeking equality’. For the middle socioeconomic group the dominant theme was ‘battle for quality of life’ and for the lower socioeconomic group the dominant theme was ‘the unfair advantage of others’. It is concluded that this group of chronic pain sufferers prioritize justice-related issues in terms of what is dominant to their social concerns and personal needs.

Insights into Pain: A Review of Qualitative Research

• Qualitative research exposes and explores important aspects of the pain experience that are inaccessible to other approaches. • Qualitative work adopts a different epistemological and ontological perspective to quantitative work. • Qualitative research is not well established in the field of pain, but is growing. • More interpretative engagement with qualitative data is required.

Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain.

Interpretative phenomenological analysis (IPA) is a qualitative approach which aims to provide detailed examinations of personal lived experience. It produces an account of lived experience in its own terms rather than one prescribed by pre-existing theoretical preconceptions and it recognises that this is an interpretative endeavour as humans are sense-making organisms. It is explicitly idiographic in its commitment to examining the detailed experience of each case in turn, prior to the move to more general claims. IPA is a particularly useful methodology for examining topics which are complex, ambiguous and emotionally laden. Pain is a prime exemplar of such a phenomenon: elusive, involving complex psycho-somatic interactions and difficult to articulate. In addition to the 1998 article, published in this Special Issue, two further papers are suggested that the interested reader might wish to look out for.

Assessing the properties of the WHOQOL-Pain: quality of life of chronic low back pain patients during treatment

ObjectivesAssessing subjective, patient-reported outcomes such as quality of life (QoL) is essential to health care research. This study aimed to assess the properties of a QoL measure relating to pain and discomfort: the WHOQOL-Pain. MethodChronic low back pain patients (n=133) completed the WHOQOL-Pain, SF-12, and short-form McGill Pain Questionnaire before treatment started and again 2-4 weeks later. Of these, 76 received a lumbar epidural steroid injection, and 57 were waiting to receive treatment. ResultsOverall, there was no significant difference in effect of either epidural injections or no treatment on bringing about an improvement to QoL overtime. Moderate effect sizes were found for 5 facets including pain relief and uncertainty. Small effect sizes were found for 7 facets including vulnerability, fear and worry, anger and frustration. Larger effect sizes were found for those reporting the most improvement in pain. The waiting group reported no significant changes to QoL but small changes for uncertainty. Three of the four new facets were sensitive to change and test-retest reliability (stability) was confirmed in three. DiscussionAlthough this study was not designed to test treatment effectiveness, the WHOQOL-Pain enables patients to report changes to important aspects of QoL during many diverse interventions for relieving pain.

The quality of life of people in chronic pain: Developing a pain and discomfort module for use with the WHOQOL

This article reports the development of a pain and discomfort module (PDM) designed to assess the full impact of quality of life (QoL) relating to chronic pain, which could be used with the generic World Health Organisation Quality of Life Assessment (WHOQOL). First, cognitive interviewing was completed with nine participants with chronic pain, for 108 items representing 10 pain-specific facets of QoL. Sixty-eight QoL items and 16 importance questions on pain were relevant, comprehensive, comprehensible and acceptable to users, and were confirmed to assess their purported concepts. Secondly, these items were pilot tested using a cross-sectional survey of 216 people with chronic pain, to investigate the preliminary psychometric properties of the PDM, and reduce its items statistically. All new facets were important to those with chronic pain. Sixteen items within four facets of pain relief, anger and frustration, vulnerability/fear/worry, and uncertainty were retained, and demonstrated acceptable to good internal consistency reliability (α = 0.77–0.85). The PDM is a self-administered, multidimensional subjective assessment of pain-related QoL, with potential to evaluate pain-relieving interventions, identify sufferers needs, and for survey use.

Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain:

Objectives: ‘Mental defeat’ (MD) has been identified among people with chronic pain as a type of self-processing related to social role and rank. Research has linked it to anxiety, pain interference and functional disability. The relationship between MD and other cognitive constructs, such as hopelessness and depression, remains poorly understood. This study considers the association between MD, pain symptomatology and self-efficacy in the context of other cognitive factors. Methods: In total, 59 participants completed a questionnaire pack assessing anxiety, depression, hopelessness, pain catastrophising and MD in order to examine the relationship with pain symptomatology and self-efficacy. Results: Linear multiple regression analyses showed that anxiety was most strongly associated with pain symptomatology, accounting for 26% of the variance, while catastrophising showed the strongest association with sensory pain and MD the strongest association with affective pain. Finally, MD was found to be strongly associated with pain-related self-efficacy, accounting for 47% of the variance. Conclusion: This research has demonstrated the potential importance of assessing MD in chronic pain patients, suggesting that targeting these cognitions during interventions and therapy could be valuable. Furthermore, the study indicates that MD differs from related cognitive constructs involved in pain, such as depression, hopelessness and catastrophising.

Better safe than sorry? Frequent attendance in a community hospital emergency department: an exploratory study

Introduction: Pain accounts for the majority of attendances to the Emergency Department (ED), with insufficient alleviation of symptoms resulting in repeated attendance. People who frequently attend the ED are typically considered to be psychologically and socially vulnerable in addition to experiencing health difficulties. This service development study was commissioned to identify the defining characteristics and unmet needs of frequent attenders (FAs) in a UK acute district general hospital ED, with a view to developing strategies to meet the needs of this group. Methods: A mixed-methods multi-pronged exploratory approach was used, involving staff interviews, focus groups, business data and case note analysis. Results: Findings reflect an absence of a coherent approach to meeting the needs of FAs in the ED, especially those experiencing pain. FAs to this ED tend to be vulnerable, complex and report significant worry and anxiety. Elevated anxiety on the part of the patient may be contributing to a ‘better safe than sorry’ culture within the ED and is reported to bear some influence on the clinical decision-making process. Discussion: It is recommended that a systemic approach is taken to improve the quality and accessibility of individualised care plans, provision of patient education, psychological care and implementation of policies and procedures. Change on an organisational level is likely to improve working culture, staff satisfaction and staff relationships with this vulnerable group of patients. A structured care pathway and supportive changes are likely to lead to economic benefits. Further research should build on findings to implement and test the efficacy of these interventions.

More than just being nice: the importance of rapport to understanding.

In this issue, you will find a paper by Matthias et al. (2014) titled ‘Communicating about Opioids for Chronic Pain: A Qualitative Study of Patient Attributions and the Influence of the Patient-Physician Relationship’. The authors recommend that physicians prioritize rapport building in the consultation and their paper places the physician–patient relationship in a central position with regard to making sense of chronic pain and its treatment. There is very little research in this area in the pain literature and it suggests some interesting avenues for further study. In their words, the authors recommend ‘engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient’. Despite defining pain as a multidimensional phenomenon and situating it within a dynamic, embodied, social and cultural setting, non-medical pain research often focuses on discrete cognitions or behaviours and excludes any interaction with the outside world of other people. Matthias et al. (2014) have addressed this neglect and deserve credit for also going beyond traditional qualitative individual interviews to collect naturalistic raw data. Opiates and chronic pain is a hot topic. The analgesic regimes of chronic pain sufferers are spectacularly diverse and can range from barely anything (‘because it doesn’t work’) to urgent requests for yet stronger opiates to help them manage the increased sensation and prolonged duress. Matthias et al.’s (2014) paper identifies both the long-term problems of taking opiates for chronic pain and the challenges for the physician to deny them to a pain sufferer and explain why. If the pain has become unbearable and exhausting, any arguments about long-term problems can be dismissed as irrelevant or unconvincing. Ethically, it is much easier to withhold treatment than to withdraw it, but it is not easy and it is not uncommon for something that starts out as a brief intervention to help manage a flare up, to graduate to an established escalation up the analgesic ladder. Understanding why all analgesia does not seem to work that well and how opiates can be problematic is critical in chronic pain management and not a given by any means. Matthias et al.’s (2014) study suggests that the sufferer’s understanding can be obscured and obstructed by social and moral processes at play in the consultation. Often, chronic pain sufferers do not know what medication they are taking or why. Confusion and uncertainty can persist in chronic pain sufferers despite frequent contact with services and, unlike many medical conditions, the invisibility and ineffability of pain means that the chronic pain sufferer is often anxious that their condition might be dismissed or disbelieved. They can feel under threat of judgement. Before it even begins, the pain patient– physician relationship can be subject to suspicions and prejudices that are not conducive to open and transparent communication and education. The illness experience goes beyond discrete beliefs about disease to include processes of sensemaking, self and identity. Researchers, such as Leventhal et al. (1984), have showed how we all carry around our own ‘common-sense’ representations of our conditions. These are constructed from whatever is handed to us by our biographies and social-cultural and spiritual situation. They can be resistant to modification and as such problematic. We exercise a degree of selectivity over the information we consider meaningful and this can be a significant obstacle to our development of knowledge. We are creative in our understanding of our illness situation and this does not always have a direct link with reality (Taylor, 1983). A focus on discrete pain beliefs or behaviours and a neglect of the contribution of self and identity means that we have not explored what influences sensemaking in chronic pain as much as we could have. Matthias et al.’s (2014) study reinforces the idea that the physician’s behaviour can play a critical factor in the potential of the patient to understand their pain situation. An insecure and threatened self appears to disable understanding. Those participants who felt that their doctor did not have their best interests at heart attributed the decision to withhold opiates as a personal attack, rather than a benevolent medical