the experience of loss in patients suffering from chronic pain attending a pain management group...
TRANSCRIPT
Original Article
From the Department of Health
Studies, Faculty of Social Science,
University of Stavanger, Stavanger,
Norway.
Address correspondence to Cecilie
Haraldseid, MSc, Institutt for Helsefag
University of Stavanger, 4036
Stavanger, Norway. E-mail: cecilie.
Received November 21, 2011;
Revised April 13, 2012;
Accepted April 17, 2012.
1524-9042/$36.00
� 2014 by the American Society for
Pain Management Nursing
doi:10.1016/j.pmn.2012.04.004
The Experience of Lossin Patients Suffering fromChronic Pain Attendinga Pain ManagementGroup Based onCognitive-BehavioralTherapy
--- Cecilie Haraldseid, MSc, Elin Dysvik, PhD,
and Bodil Furnes, PhD
- ABSTRACT:Chronic pain has been found to cause significant losses in the lives of
those who experience it. To improve their life situation, it is important
to understand the impact of these losses and manage them effectively.
The aim of this study was twofold. We wanted to investigate which
phenomena in the lives of patients with chronic pain could be de-
scribed as experiences of loss, and whether a cognitive-behavioral
therapy (CBT)–based group approach could help them process such
losses. A qualitative approach based on semistructured interviewswith
six patients was chosen to investigate the experiences of patients with
chronic pain. The findings in this study indicate that the patients ex-
perienced several losses: loss of ability to engage in meaningful activ-
ities, loss of relations with others, and loss of self. The experience of
loss in their life situation can be difficult for them to deal with and
creates a need for support and guidance. The study indicates that par-
ticipation in a CBT-based group that focuses on processing these losses
can be beneficial in helping patients identify and accept the losses and
changes they have experienced, and thereby change their behavior
toward a meaningful life despite their chronic pain. Failure to address
these losses may result in patients obtaining few of the benefits that
could be gained from pain management groups. Because the findings
point to the synergies among several components in the program, it is
difficult to isolate the effects of a single component. The conscious use
of CBT-based elements, i.e., changing behavior by changing thoughts
and feelings, in the pain management group seemed to help them to
process the losses through new insight and understanding.
� 2014 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 12-21
13Experiences of Loss in Chronic Pain
In Norway, chronic pain affects 30% of the adult popu-
lation (Breivik, Collett, Ventafridda, Cohen, & Gallacher,
2006), an incidence nearly double that of neighboring
European countries (Rustøen, Wahl, Hanestad, Lerdal,
Paul, & Miaskowski, 2004). Patients with chronic pain
experience considerable losses as a result of the multi-
ple impacts it has on several aspects of their lives(Roy, 2008).
The experience of loss is universal to human life.
During the life span we experience losses of different
types and magnitude, and perhaps death can be seen
as the ultimate loss (Miller & Omarzu, 1998). Loss may
vary from person to person and is defined individually
(Harvey, 2000). Miller and Omarzu (1998) defined loss
as life events or changes that can result in someone be-ing or feeling deprived of something valuable. Chronic
pain is seen as a statewith the potential to leave a person
feeling deprived of what he or she values because of
compromises or losses (Roy, 2008). Living with chronic
pain has been found to cause losses in different aspects
of life (Gatchel, Adams, Polatin, & Kishino, 2002;
Walker, Sofaer, & Holloway, 2006) and these losses po-
tentially change how patients with chronic pain thinkof and perceive their lived world.
Researchers emphasize that it is important to ad-
dress loss in all rehabilitation programs to ensure com-
passionate treatment for patients with chronic pain
(Gatchel et al., 2002). Recent findings suggest that pa-
tients who suffer from chronic nonmalignant pain expe-
rience grief related to loss similar to the grief caused by
death (Furnes & Dysvik, 2010a); while Harvey (2002)states that the aim of dealing with grief should be to
learn to live with the loss. Treatment options for pa-
tients with chronic pain should therefore help patients
adjust to their new life situation by addressing loss as
a specific experience (Furnes & Dysvik, 2010a). How-
ever, there are few reported intervention strategies
and literature on the topic is scarce (Roy, 2001).
Pain is both a sensation and an emotional experi-ence that includes the individual’s thoughts and feel-
ings (Turk, 2003). Living with pain influences both
well-being and mental and physical performance.
Basler, Jakle, and Kroner-Herwig (1997) argued that
a cognitive-behavioral therapy (CBT)–based treatment
could be beneficial for patients experiencing chronic
pain because it takes into consideration that chronic
pain is a multifaceted phenomenon, not merely a neu-rophysiologic state. CBT aims to change behavior
through changing a person’s thoughts and feelings,
based on the belief that people themselves are instru-
ments in developing and maintaining maladaptive fea-
tures (Turk, 2002). According to Furnes and Dysvik
(2010a), research and practice that consider losses in
the lives of patients with chronic pain will be valuable.
Research is therefore needed into the benefits of a CBT-
based pain management group that addresses loss for
patients with chronic pain.
Based on this background, the present study’s aim
was twofold. We wanted to investigate which phenom-
ena in the lives of patientswith chronicpain could bede-
scribed as experiences of loss, andwhether a CBT-basedgroup approach could help them to process such losses.
METHOD
A phenomenologic approach with semistructured in-
terviews (Appendix A) was used to explore the lived
experience of patients living with chronic pain
(Kvale, 2006). The study was conducted with six pa-
tients suffering from chronic pain who had completedan 8-week CBT-based pain management program.
(Appendix B) Interviews were conducted 6 months af-
ter completion of the program to give participants the
opportunity to reflect consciously on their losses and
decide whether the pain management program had
helped with the processing of them.
ParticipantsSix participants were recruited through a learning and
coping center at a university hospital in Norway as part
of a greater study. They were all members of one pain
management group and had taken part in an ongoing
rehabilitation program. Recruitment was done in col-
laboration with the leaders of the group who initiated
contact with potential participants. To be assessed for
group participation, the participants underwent face-to-face interviews by the nurses at the learning and
coping center before inclusion.
Inclusion criteria for participation in the pain man-
agement program were set before the study. They in-
cluded age 22-65 years, not affected by major mental
disorder or serious medical conditions, medical investi-
gation and/or treatment completed, motivated to par-
ticipate in an active rehabilitation program, assessedas suitable for group participation, and able to write
and speak fluent Norwegian. Specific criteria were
added for those who participated in the present study:
completion of the 8-week program, attended follow-up
at 6 months, and willing to give informed consent.
The participants were three men and three women
with an average age of 43 years (range 32-55 years).
Only one was employed at the time of the interviews.Five had children, and four were living in relationships.
Data CollectionInterviews lasted 40-60 minutes and were conducted in
the learning and coping center. The semistructured in-
terview guide was designed to capture experiences of
TABLE 1.
Example of Three Interpretation Levels
Self-UnderstandingCommon-SenseUnderstanding Theoretic Understanding
Don’t want to go out with pain, lovedtraveling, took annual trips, sad notbeing able to travel anymore.
Loss of ability to engagein meaningful activities
Development of self—Mead (2005)
Hold ‘‘it’’ on the inside, put makeup on,twinkle in my eyes, collected energyfor three days, finally make it, hope manycan see how healthy you look. Not atypical love relationship, only have childrentogether, that’s how it has become
Loss in relation to others Recognition of others—Schibbye (2009)
Everyone else works, then the lonelinesscame, I had to be home, I lost my network.
Loss of self Development of self—Mead (2005)
14 Haraldseid, Dysvik, and Furnes
loss in the livesof chronicpainpatients and to investigate
whether a CBT-based group approach had helped them
process such losses. Themes thatwere covered included
social networks, work situation, self-esteem, feelings ofcontrol over own destiny, thoughts about the future,
and experiences from the group participation.
Data AnalysisAll interviews were recorded and transcribed by the in-terviewer within a day of the interview. The tran-
scribed interviews were analyzed with the use of
Kvale and Brinkmann’s (2009) qualitative research
method with three levels of interpretation (Table 1).
The first step, referred to as subjects’ ‘‘self-understand-
ing,’’ entailed reading through each transcript several
times to get an impression of what was being said.
Meaning units were extracted from the text and orga-nized under different preliminary themes. The mean-
ing units were then condensed and given codes. In
the second step, critical common-sense understanding
was used to add a reasonable assumption of what was
being said to the participants’ statements. The codes
were then labeled and organized under new themes,
and the themes were illuminated by theory. The third
step, theoretic understanding, enables the researcherto interpret the data within a theoretic frame (Table 2).
Ethical ConsiderationEthical approval was obtained from the Regional Com-
mittee for Medical and Health Research Ethics. Each par-ticipant receivedwritten information about the study by
mail, including information about their right towithdraw
from the study at any point without any negative conse-
quences. Signed informedconsent formswerehanded to
the group leader by those who wanted to participate.
The participants’ identitieswere then revealed to the au-
thor, who contacted them to schedule interviews.
FINDINGS
In this section experiences of loss followed by experi-
ences from group participation are discussed.
Experience of LossThe first part of the interview guide focused on differ-
ent experiences in the lives of participants with
chronic pain that could be understood as loss. The em-
pirical material indicated that the patients mainly expe-rienced loss in connection with three different aspects
of life: loss of abilities to engage in meaningful activi-
ties, loss of relations with others, and loss of self.
Loss of Ability to Engage in Meaningful Activities.The central finding was loss of work, social activities,
physical activities, and hobbies. As a result of chronic
pain, participation in these activities was no longer
possible, which has therefore been understood asloss.
As a direct result of the chronic pain, most of the
patients had to give up their work, because their phys-
ical limitations rendered them incapable of fulfilling
workplace demands. The loss of employment influ-
enced them highly, because it was seen as an important
part of their life: ‘‘I miss it tremendously! The work
was my life! That’s what mattered: a kind of corner-
stone.’’ Some of them felt forced out of their work-
places as a direct result of frequent periods of sick
leave: ‘‘It was exactly the work I wanted . so it
was an extra big loss when I was asked to leave,
due to excessive amounts of sick leave.’’
TABLE 2.
Illustration of the Analysis Process
15Experiences of Loss in Chronic Pain
Their loss of employment was in no way wanted
and as a consequence they were forced to receive socialsecurity or welfare: ‘‘So now I receive social security
and I can not work, something I wish from the bottom
of my heart that I could.’’ The reduced income created
economic restrictions that kept them from participat-
ing in social activities: ‘‘you can not afford this and
that . so those things disappear, and then there are
more and more people that pull away, and you are
left with few friends, very few.’’ Hobbies and previousphysical activities were also affected. One of the partic-
ipants had loved traveling, but this was now impossible
because of the difficulty of spending prolonged time in
one position. Playing soccer, knitting, fishing, and par-
ticipation in mountain hikes were other activities that
were now difficult or impossible for them.
Loss of Relations with Others. Loss of close rela-
tionships with spouses, children, parents, and friendswas seen as the greatest loss. Participants often found
that others did not understand them or questioned their
behavior and decisions. In turn, participants refrained
from telling others how they felt, because of not want-
ing to complain, trying to keep up appearances, and the
need to protect both themselves and others: ‘‘I’ve
learned to keep my mouth shut, not to talk about it.
It serves no purpose.’’ This poor communication oftenseemed to cause misunderstandings, distance, and con-
flicts in their close relations.
Participants lacked the capacity they once had to
contribute and join in as spouses, friends, daughters,
sons, and parents: ‘‘With the kids, I might just join
in on that one activity, not able to be there all the
time, but just at that one thing.’’ Changes caused bychronic pain especially affected relationships with
their spouses: ‘‘It’s not the typical love relationship I
would say. It’s more the fact that we have children to-
gether . that’s just how it has become.’’
Chronic pain influenced their moods, their ability
to work, and their opportunities to participate and
contribute, resulting in reduced social contact. The
shift from their previous active lifestyle to a more iso-lating existence caused them to lose part of their net-
work: ‘‘What I miss the most may not be what I did
there, but the people around me.’’
Loss of SelfThe main areas of attention regarding loss of self were
related to how they had changed as persons and their
thoughts about themselves. Some of them experiencedmajor alterations in cognitive function because their
ability to concentrate and short-term memory were
affected. Problems with concentration and memory
affected both work and self-esteem: ‘‘I worked, but I
took three times longer than I used to . It’s just
not how I work. I don’t want to be sitting there doing
mumbo-jumbo.’’ Others experienced poor sleep qual-
ity, reduced appetite, and excessive sensitivity totouch. Some felt bad tempered, became easily irritated
or angry, and experienced frequent altered moods.
One of them said, ‘‘I get really angry when things
don’t work . when I can not do stuff and I am tired
and exhausted. I can feel I have a lot of anger.’’ They
16 Haraldseid, Dysvik, and Furnes
also reported changes in their physical ability: ‘‘It’s
frustrating when you no longer can do what you
are used to.’’
The changes in their lives caused by the chronic
pain led to changes in their feelings about themselves
and their identity: ‘‘I lost that identity, because it
means a lot when you have studied for a long time
and finally start working . that broke me down.’’
Feelings of being misbelieved and not understood by
others often triggered the need to hide behind
a mask. It was often important for them to present
themselves as ‘‘normal,’’ not showing the world around
them how they really felt: ‘‘It’s because of your self-
worth, who you are, and who you want to show it
to.’’ The participants often felt judged and stigmatizedby the people in their surroundings, which seemed
to influence how they perceived themselves.
The chronic pain had also caused the participants
to believe they were no longer fulfilling their commit-
ments as spouses, friends, children, and parents:
‘‘I don’t feel I manage to be a good-enough mother,
even though my daughter reassures me I am, I
don’t feel like it.’’
Group Participation ExperiencesThe second part of the interview was designed to show
whether elements of a CBT-based group had helped
them process the losses they had experienced. The par-
ticipants emphasized the climate of warmth and social
support within the group as important elements of
group participation. In addition, they identified home-
work tasks that included self-help education material as
important.Group Climate. Referring to thegroupclimate, several
of the participants pointed out fellowship, understand-
ing, and trust as important elements in creating a good
group atmospherewhere they could share their feelings.
One of the participants said, ‘‘We soon gained trust in
each other when it was totally clear that what was be-
ing said in the group, remained in the group.’’ Trusting
each other enabled them to share their life stories.Whensharing their feelings it soon became clear that others
also experienced similar problems: ‘‘Most of the group
participants dug deep and shared, there were a lot of
tough stories, and then you see you are not the only
one to struggle.’’ Through sharing their feelings, they
discovered that others had similar problems, and this
created fellowship, understanding, and acceptance.
Social Support. The importance of social supportemerged without any specific questions from the inter-
viewer. All participants talked about the importance
of having someone with similar experiences who un-
derstood and supported them. When revealing their
problems, common experiences were illuminated: ‘‘I
recognized myself in everything he said! Everything!
It was like: ‘Yes! Yes! Yes!’’’ According to this partici-
pant it was easier to understand each other when
you knew you were talking the same ‘‘language’’ and
because you knew you were understood: ‘‘You feel
a companionship, not to whine or complain, but
you feel that people know what you mean when
you say you have not been able to get into the shower
today. People know what it means.’’
Homework Tasks. In addition to being a part of
a group, the participants were given homework tasks
during the program that they now used in their every-
day life. Relaxation techniques and therapeutic writing
were mentioned particularly as effective techniques byall of the participants. One of them described the im-
portance of relaxation techniques like this: ‘‘You man-
age your pain better. You know what to do now! If it
starts to reach the top.’’ The use of writing as a process-
ing tool was described as tough but rewarding work.
One of the women described it like this: ‘‘To dare being
honest to yourself . I had to swallow a few camels
there. But I learned a lot.’’ Making participants writedown their thoughts and feelings led to reflection about
different situations and enabled them to identify prob-
lem areas in their everyday lives: ‘‘After you had written
it down, you gained a new focus, you shared with
others, and you got advice and guidance.’’
DISCUSSION
The aim of the study was twofold, to investigate phe-nomena in the lives of patients with chronic pain
that could be explored as experiences of loss, and
whether a CBT-based group approach could help
them process such losses. The discussion follows the
same sequence as the Findings section.
Experiences of LossThe findings in this study indicate multiple losses inthe lives of patients suffering from chronic pain. Loss
of ability to engage in meaningful activities, loss of re-
lations with others, and loss of self have also been
found in earlier research investigating experiences of
patients with chronic pain (Walker et al., 2006). Other
previously reported themes include not being under-
stood by those around them and feeling changed as
a person (White & Seibold, 2008), both of whichwere found in our study.
A major finding in the present study was that all
participants lost their ability to engage in activities
that were important and meaningful for them. This
seemed to influence their well-being and caused them
17Experiences of Loss in Chronic Pain
to experience loss. Schibbye (2009) states that the per-
sonwe are depends onwho the people around us allow
us to be. Personhood is created in a context of social re-
lations and we change roles depending on the situation
and the people around us. Roles and identity shift when
chronic pain prevents someone from engaging in what
was previously taken for granted (Henare, 2003).Abra�ıdo-Lanza and Revenson (1996) found that impor-
tant role identities contribute to competence, self-
esteem, and self-efficiency. Loss of these roles through
chronic illness therefore had a devastating impact on
psychologic well-being. Compared with the present
study, those findings reflect the participants’ experi-
ences of how changes in their ability to undertake
meaningful activities affected their perceived importantroles and ultimately caused them to experience a sense
of loss, influencing their well-being.
Participants reported that loss of employment con-
tributed to loss of identity, meaning, and self- worth,
leaving them feeling unwanted by society. According
to Roy (2004), work is one factor that appears to define
identity, because it ranks people in social positions and
gives them specific roles. In addition, he claims that lossof work includes the risk of losing social interactions
and friends. Walker (2010) supports these findings; he
found that loss of employment not only affects income,
but also social interaction and chosen identity, forcing
people to adapt to a deviant role in society. The loss
of meaningful activities thereby seems to influence
their lives, causing them to lose old roles and being
forced into new, unwanted roles.All participants described various problems in
their relationships with others. Several participants
found relations with children, spouses, and parents
to be most difficult. They described how they re-
frained from explaining about their pain because their
feelings were not understood by those around them.
Schibbye (2009) states that acknowledgement may
be lost if two acknowledging subjects are not able toswitch imaginary roles and understand the opposite
person’s view. Interpersonal relations may suffer
from the lack of mutual understanding, which causes
the relationship to come to a halt. The inability of the
pain sufferers and their significant others to see things
from each other’s perspectives could therefore ex-
plain aspects of why the participants had refrained
from communicating, leading to problems in the par-ticipants’ relations.
Participants indicated that they, and especially
their relations within the family, had been influenced
by their inability to participate and contribute as be-
fore. When Kryst and Scherl (1994) investigated the
social and personal impacts of headache in Kentucky,
they found that efficiency at work, attendance at
social events, capacity for planning ahead, relations
with friends, and self-image were all reported to be af-
fected. Smith (1998) also found that a majority of mi-
graine sufferers reported their pain as having
significant impact on their families. According to
Lyons and Sullivan (1998), illness and disability never
occur in a vacuum for the individual alone, but exist ina context of social relationships, and interpersonal
losses are therefore inevitable. We are born into a com-
munity, constantly have to relate to the people around
us, and therefore ‘‘relations to others are both the
most important and the hardest for us,’’ according to
Øiestad (2009, p. 36). The loss of their ability to par-
ticipate and contribute therefore caused loss of rela-
tions with their close family.In addition to their inability to engage in meaning-
ful activities and loss of their relations with others, the
present study indicates that participants experienced
a loss of self. The personal changes caused by chronic
pain seemed to make them become different in
mood, thoughts, behavior, and feelings of self. Identity
is defined as something that comprises who we are
and our characteristics as unique persons (CollinsDictionary, 1979). Our self-definition is based on our
perception of what and who we believe we are. We ex-
perience a great deal of well-being through our ability
to meet the demands and obligations placed on us as
workers and spouses (Roy, 2004), an ability that can
be lost because of chronic pain. Facing chronic pain
does not relieve someone of their role as a spouse,
but it may make the fulfillment of its obligations harder(Roy, 2004). Participants’ personal changes had altered
the characteristics that made up who they were, and
this seemed to affect their ability both to fulfill roles
and to make changes, leading to a sense of loss of self.
Loss of self also included the aspect of changed
thoughts about themselves. Participants’ thoughts con-
sisted of how they were perceived by others and how
they perceived themselves. Christiansen (1999) de-scribed identity as a composed definition of self, and
argued that identities are socially interconnected. Be-
cause identity is shaped through interaction with
others, loss of identity is closely connected to losses
in interpersonal relations. This pattern is circular; if
a person changes it could affect the lives of those
they are involved with (Kelley, 1998). Findings in the
present study could therefore indicate that loss of rela-tions influences participants’ feelings of self, and this is
consistent with Mead’s (2005) view that the individual
perception of self does not occur directly, but occurs
as a reflection of the distinct perspectives of other
members of his or her social group. Gatchel et al.
(2002) reports that negative social perceptions con-
tribute to distress and enhance difficulties in managing
18 Haraldseid, Dysvik, and Furnes
life situations. A negative perception of self and as-
sumed negative perceptions from others will therefore
have the potential to affect the person’s feelings of self.
Roy (2008) also states that social roles constitute the
main center of one’s identity.
The inability to engage in meaningful activities and
loss of relations ultimately seemed to influence partici-pants’ identity and feelings of self: ‘‘It becomes a strug-
gle wherever you turn.’’ Henare (2003) stated that one’s
roles, activities, occupation, and tasks reflect one as
a person. Losing the ability to participate in meaningful
activities and loss of relations with others because of
chronic pain could make sufferers begin to lose their
sense of self. There appears to be, therefore, a close re-
lationship between these three aspects that were previ-ously considered separately: the loss in ability to engage
in meaningful activities, loss of relations, and loss of self.
Group Participation ExperiencesThe second aim of the present study was to explore
whether the CBT-based group approach helped partici-
pants process the losses they had experienced. The
study indicated that group climate and social support,
together with homework tasks, had been essential in
identifying problem areas and managing everyday life.The group climate was important to participants,
because it created a trusting environment where they
could disclose themselves and find understanding and
support from people with shared circumstances. This
finding is supported by Thorn and Kuhadja (2006),
who stated that group formats fulfill a supportive func-
tioning, allowing patients to share their inner selves to
others with similar circumstances. The establishment ofa positive group climate, therefore, created a fertile envi-
ronment for disclosure of their thoughts, which seemed
to help them identify losses and problems they had in
commonwith others in the group.MacKenzie (1990) ex-
plains that self-disclosure is at the heart of group partici-
pation because it is essential for identifying problems
and learning from each other. The group climate seems
to be important, therefore, to enable self-disclosure.The discovery of common losses seemed to create
understanding and social support in the group. Sharing
stories also made participants realize that they needed
to communicate with those around them and tell them
how they felt and what they needed. Communication
and a shift inperspectivehelped themto thinkdifferently
about their situation and gave them the opportunity to
work on their problems. They also realized that changedepended on their own efforts and active participation.
If they wanted to change, they had to do the work
themselves. The combination of good group climate
and social support seemed to help them accept and ac-
knowledge their losses and problems, making them
receptive to change. MacKenzie (1990) further states
that self-disclosure creates a forum for modeling and
learning from each other that can lead to changed
behavior.
Homework included therapeutic writing around
specific themes. This seemed to help participants to re-
flect on their thoughts, put their problems into focus,and identify losses in their lives. Several findings empha-
size the importance of writing as a tool in the recovery
process after loss experiences for adapting to the new
life situation (Furnes, 2008; Furnes & Dysvik, 2010b).
Reported changes as a result of group participation
included gaining a new perspective, acknowledging
one’s limitations, and starting communication with
those around them, and these were seen as importantfactors in participants gaining improvements in their
day-to-day lives. Taylor (2006) stated that it is important
to help chronically ill patients realize and manage role
changes, accept new limitations, and embrace other
qualities and strengths. Risdon, Eccleston, Crombez,
and McCracken (2003) found that one of the keys to
living with pain was acceptance. Factors contributing
to this included taking control, empowerment, andaccepting loss of self. The participants seemed to have
gained acceptance of their changes through identifica-
tion and understanding during the group process.
CBT aims to change a person’s behavior by chang-
ing thoughtpatterns andexperiences aroundaphenom-
enon (Wilhelmsen, 1997), which naturally includes
loss. Chronic pain is a complex phenomenon in which
several biopsychosocial aspects are involved. To handlesuch aspects, the present study emphasized that the
connection between thoughts, feelings, and behaviors
was of importance in moving participants toward
acceptance of their altered life situation. Processing
losses, as achieved through pain management groups,
seems to cause awareness of the loss and enables
patients to search for new valuable life goals. Several
studies have indicated that the cognitive-behavioral ap-proach is beneficial for patients suffering from chronic
pain (Aggarwal, Tickle, Javidi, & Peters, 2010). Group
delivery of CBT is effective because it gives participants
the opportunity to meet others with similar experience
and feelings, while at the same time they are confronted
with their own thoughts and actions (Keefe, Beupre,
Gil, Rumble, & Aspnes, 2002), as shown in the present
study. It is reasonable to assume that nonspecific effectsof such group approaches, such as being in a group and
group climate, may constitute additional explanations
to the experiences of loss and suffering (Newthon-
John & Geddes, 2008).
Overall, the participants were positively surprised
with the management program. All identified losses
and learned the importance of addressing and
19Experiences of Loss in Chronic Pain
processing these losses. Some experienced more ben-
efits than others, and although several regretted the
lack of follow-up after the course, they still found the
program to have been useful.
Methodologic ConsiderationsInterviewing participants about something as personal
as loss is a challenge and may lead to possible withhold-
ing of personal information. However, the descriptionsin this study are extensive and detailed, covering sev-
eral aspects of the phenomena studied. Validation of
the study was obtained through three contexts of inter-
pretation using Kvale and Brinkmann’s method (2009).
The self-understanding level was validated through
member validation between the interviewer and each
participant. The quality of data and results of analysis
are highly dependent on the skills of the interviewerand the rigor of the analysis. The critical common-
sense and theoretic understandings were validated by
coworkers individually analyzing the empirical mate-
rial before reaching a consensus. Because the findings
point to the synergies among several components
in the program, it is difficult to isolate the effects of
a single component (Morley &Wiliams, 2002).The au-
thors suggest that transferability of the findings may
be relevant to other patient rehabilitation groups in
similar situations.
CONCLUSION
Results from this study show how several losses causedby chronic pain could have an impact on the entire ex-
istence of patients living with chronic pain. Findings
indicate that it is valuable to address loss through
a CBT-based group to initiate changes in the lives of pa-
tients with chronic pain. Group climate, social sup-
port, and homework tasks seem to be important
contributing factors. The conscious use of CBT-based
elements, i.e., changing behavior by changingthoughts and feelings, in the pain management group
seemed to help them processing the losses through
new insight and understanding. Failure to address los-
ses may result in patients obtaining few of the benefits
that could be gained from pain management groups.
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21Experiences of Loss in Chronic Pain
Appendix A: Interview Guide
Identification of Loss:Which experiences could be explored as loss?
Group Therapy:How can a CBT-based pain management group help them
process such losses?
� If you think about your life before and after the onset ofthe chronic pain, what will you say is different regarding:—Relations to spouse/friend—Self-esteem—Social network—Work—Thoughts about the future—Control over own destiny
� No identification of loss?—Is there anything in your life right now you willdescribe as a loss?
—What does loss mean to you?
� What has changed in your everyday life after partici-pating in the pain management groups?—Any situations you now react different to? Do youhave an example?
� Which elements, connected to the group process, waspositive/negative to you?—Group climate?—Methods used?—Which relationship did you develop to the others inthe group?
—New reflections after participating in the group?� Any supplements to the themes we have covered?
Appendix B: Content of the Pain Management Program
Meeting
1 Establishing the group. Develop goals.2 Physical activity and pain. Develop own plan for activity.3 Pain as a complex phenomenon. Awareness of factors increasing/decreasing pain.4 Muscle tension, relaxation and pain. Practice in relaxation techniques.5 Coping and pain. Awareness of coping strategies and alternative ways of coping.6 Self-esteem, social network, and pain. Awareness of self-esteem and social network and alternative
ways of behaving.7 Thoughts, feelings, and behavior and how they relate to each other.8 Communication. Self-help. Awareness of important factors in communication.9 Nutrition and pain. Awareness of how nutrition can influence pain.
10 Repetition, main goals, basic assumptions.