Living well with chronic
pain
A practical theory for clinicians
BF Lennox Thompson, PhD
Jeffrey Gage, PhD
Ray Kirk, PhD
University of Canterbury, Christchurch, New Zealand
What do you do when you see something
weird?
First steps
And then I enrolled in a PhD
• To explore my observation that some people
live well despite
– Having moderate pain levels
– Not being seen at pain management centres
– There being no cure for their pain problem
Living well with chronic pain
• Rarely studied because?
– Difficult to access
– Not demanding (ie uses few resources, not a priority)
– Research focus is typically on what doesn’t work
• Little existing theory
BUT
• A consistent minority
• An empirical regularity (eg Karoly & Ruehlman, 2006;
Mortimer, Ahlberg & Group, 2003; Dominick, Blyth &
Nicholas, 2011)
• Could we learn from them?
Why not test a hypothesis?
• Existing theory explains disability, not
resilience
• No reasonable hypotheses to test
• Many assumptions needed to test hypotheses,
with limited empirical basis
• Relatively small population
• Wanting to begin with individual experience
first
Paul Thurlby for the Guardian
Why grounded theory?
• Uses “real world” data to generate theoretical
relationships (hypotheses) between abstract
concepts
• Systematic, complete methodology, not just a set
of methods
• Answers the questions of why and how
• Especially in the absence of theoretical
explanation
• Reduces the problem of developing weak theory
• Pragmatic – must fit, work, be relevant and
modifiable
How does it work?
• Developed by Glaser & Strauss in 1964/65
• Divergent development since then
– Glaser’s Classical GT (pragmatist, realist)
– Strauss and Corbin’s GT (post-positivist)
– Charmaz’ constructivist GT(constructivist)
• All feature
–
–
–
–
Constant comparison
Purposive iterative sampling
Coding and sampling carried out from the beginning
Codes derived from the data rather than from pre-existing
theory
– Saturation
– Abductive reasoning
Why useful in pain research?
• Pain is subjective, rely on people telling us what is
going on
• Enables strong hypotheses to be developed for
future testing
• Allows for novel phenomena to be explored
• Examines and explains processes, interactions
both social and individual
• Integrates existing research
• Can directly inform clinical practice
Research strategy
• Identify members of the “resilient” population
• Ask them about their “main concern”
• Examine how they resolve their main concern
using data from them and about them
– Data can be qualitative or quantitative
• Constant comparison – systematically
compare each incident with each incident to
develop concepts and relationships
Research Process
• Identify core concept - saturation
– coding is then focused on codes relevant to the
core concept
• Develop theoretical coding (relationships
between the core and subsequent concepts)
• Memos document thoughts, hypotheses,
theoretical reflections and potential
relationships
• Literature is integrated during theoretical
coding
Re-occupying self
• Main concern = achieving self-coherence
• Being comfortable with the self again
• Living with the self, knowing and integrating
aspects of self including self-with-pain
• Integrate the effects of pain on capabilities,
but pain does not define the self
• Occupations used to understand meaning of
pain, represent/enact valued aspects of self,
elicit need for coping
Main concern = achieving self-coherence
Re-occupying self
Making
sense
Diagnostic
clarity
Symptom
understanding
Deciding to get on with
life
Occupational
existing
Occupational
engaging
Turning Point decision is influenced
by a Trustworthy Clinician
and
Occupational Drive
Flexibly
persisting
Coping
Future
planning
“The real travesty of pain isn’t the pain
part,
it’s the failing to live part”
Implications
• Learning to “live well” is a process – takes
time
• “Tasks” within each phase need to be
completed before moving forward
• If tasks incomplete, individuals may be
distressed, disabled, stuck
• Treatment providers influential
• Coping is contextual, functional not
categorical
How this theory can be used
• Aligns well with ACT
• Consider the person’s place in the process of reoccupying self
• Provide support appropriate for this phase
• Be explicit about:
– Chronicity
– Safety to move
– Your contribution as “trustworthy” support
• Enable symptom understanding – help develop
awareness of patterns/variations in pain
How this theory can be used
• Light the fire! Identify occupation the person
is passionate about
• THEN you can expand the coping repertoire
and how flexibly strategies are applied
• Use decisional balance when deciding
• Use NNT as part of deciding about treatment
• Values clarification can be useful if the person
can’t resume usual occupations
Contentious aspects
• Accepting pain as ongoing
– Some argue that pain reduction should be an
ongoing focus
• Symptom understanding
– Includes monitoring variations, influences
– Contrary to behavioural model
• Occupational existing
– Inability to plan for the future while making sense
Contentious aspects
• Coping strategies
– Contextual, not “active vs passive”
– Range of strategies
– Willingness to learn these depends on position in
process
• Emphasis on re-occupying self
– Often not explicitly discussed
– Requires focus on occupations the person values, not
always “work”
– Return to employment may be easier if the person
gains confidence within a less demanding or more
rewarding occupation (highly valued)
Limitations
• Substantive theory
• Probable explanation (abductive reasoning)
• Need to test hypotheses in different
populations
• Population initially drawn from people with
rheumatological conditions, may not apply to
all people with chronic pain
More from Jo
Acknowledgements
My supervisors Dr Ray Kirk and Dr Jeff Gage, University of Canterbury
My colleagues at Dept of Orthopaedic Surgery & Musculoskeletal Medicine, University
of Otago, Christchurch
The participants who shared their experiences, and particularly Joletta Belton for
allowing me to share excerpts from her blog
References
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