the experience of loss in patients suffering from chronic pain attending a pain management group...

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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. [email protected] Received November 21, 2011; Revised April 13, 2012; Accepted April 17, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.04.004 The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy --- 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 interviews with 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. Ó 2014 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 12-21 Original Article

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Page 1: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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.

[email protected]

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

Page 2: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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

Page 3: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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.’’

Page 4: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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

Page 5: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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

Page 6: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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

Page 7: The Experience of Loss in Patients Suffering from Chronic Pain Attending a Pain Management Group Based on Cognitive-Behavioral Therapy

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

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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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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.