"IT'S A WHOLE LOT MORE THAN JUST ABOUT MY PAIN": Understanding and Responding to the Social Dimension of Living with Chronic Pain

Chronic pain has been identified as a major and underestimated health care problem, with extensive individual, social and economic ramifications. It has been estimated that the annual economic cost of chronic pain in Australia exceeds AU$34 billion. The available epidemiological evidence suggests chronic pain is a relatively common health problem in Australia which is a significant public health issue. Chronic pain is a complex phenomenon which is not easily defined. However, it is important to consider the ways in which chronic pain is conceptualised, as this can have significant implications for the individual in terms of how they think about their pain, and the way they are treated within the health care system and the broader society. In the late nineteenth and early twentieth centuries, pain was predominantly considered a symptom of a biological problem in the body. Absence of physical disease was thought to indicate pain was the result of aberrant psychological processes. However, chronic pain proved resistant to this ‘mind-body’ approach, and the lack of efficacy of many biomedical interventions, combined with an apparently increasing prevalence of chronic pain, pointed to the inadequacy of purely biomedical approaches to pain treatment. The latter part of the twentieth century saw the recognition of pain as a multidimensional experience influenced by the interaction of numerous biological, psychological and social factors. Consequently, the biopsychosocial model of health, which emphasised such a ‘holistic’ perspective, gained substantial recognition in the pain management domain, and was endorsed as the preferred model of pain management. This has contributed to the development of new approaches to chronic pain treatment, particularly in the area of cognitive behavioural therapy and the establishment of multidisciplinary pain centres. There is evidence, however, that the ‘promise’ of the multidimensional conceptualisation and treatment of chronic pain has not been realised in the daily lives of people with chronic pain. Review of the literature indicates a tendency for research and practice to focus on the biological and psychological aspects of chronic pain, while minimising social environmental factors, such as the health care system and cultural belief systems regarding pain, which may also be significant. This thesis proposes that in order to more comprehensively respond to the complex phenomenon of chronic pain, it is necessary to further develop the social domain of the biopsychosocial model. A study was conducted to explore and describe individual experiences of living with chronic pain, as a basis for improving knowledge about the influence of the social environment on the individual. The thesis focuses not only on the individual descriptions of living with chronic pain, but also on the inter-relatedness between the individual and their social environment. Further, this thesis uses a process of critical interpretive analysis to identify aspects of the social environment which can exert a constraining or enabling effect on the individual with chronic pain. The thesis draws on critical realism theory, particularly the morphogenetic approach developed by Archer (1995), to guide the analysis process and to develop potential strategies for addressing identified social disadvantages. The integration of the individual stories of living with chronic pain with an interpretive analysis process, and the underlabouring philosophical perspective of critical realism, provided the framework to investigate the influence of the social environment on individual experience of living with chronic pain. In this thesis, a journey metaphor is used as an overarching framework to tie together the three principal themes identified through the analysis of the interview transcripts. The themes focused on the biomedical, psychological and cultural paths that participants followed in search of understanding and cure for their pain; the social suffering they experienced through lack of understanding and legitimation of their condition; and the identification and development of strategies for living with chronic pain. The thesis highlights the critical importance of focusing not only on the individual with chronic pain but also on the social environment within which the individual lives, and the ways in which these domains intersect and influence each other. The social environment was found to condition the individual and others in society, including health care practitioners, in relation to how they think and behave regarding pain, which in turn can have enabling or constraining consequences for the individual with pain. In particular, cultural beliefs about ‘normal’ pain, and the material structures of the health care system and employment and work places, were found to have a potentially negative impact on the individual with pain. It is concluded that these aspects of society will continue to exert constraining influences on people’s lives until the focus of policy and practice is expanded to include not just the individual with pain, but also the social environment in which they live. To address this, a number of policy and practice improvements are suggested.