Stories about bodies: A narrative study on self-understanding and chronic pain

Abstract

Objective. To explore experiences from a process of change for women with chronic pain. Design, setting, and subjects. A group-based treatment programme was intended to increase the awareness of how attitudes, habits and bodily practices are established, developed, and can be transformed, and thereby probably reduce pain. A single case story from this treatment programme is presented. A semi-structured interview was conducted with all participants about their experiences after completion of the programme. All eight women reported that they had benefited from participation. From these interviews a single case was chosen to represent the study's findings. A narrative analysis was conducted, focusing this patient's story from a phenomenological understanding of the body. Results. The patient's story illuminates how events and experiences can be connected, and how she interprets her contemporary situation in the light of previous experiences. In this way, she alters her understanding and develops a new approach to her situation. Her story demonstrated how symptoms can be understood as the result of stressful habits that the body has developed as a reaction to demands from the surroundings. Conclusions. Reflection on how the body functions may lead to a new realization of how phenomena are interconnected, thus making changes possible.

• Case study
• family practice
• mind–body relations
• myofascial pain syndromes
• narrative medicine
• self-concept

Physiotherapists are often able to demonstrate bodily changes in patients with chronic pain, even when doctors make no objective findings. The patient holds her breath, her back and neck are stiff, and she has poor balance [1], [2]. The physiotherapist's finding may help us to understand how the pain is triggered and maintained in the individual patient, but tells us nothing about why the patient has developed strain-filled bodily habits.

According to a phenomenological perspective, our natural acceptance of the human body develops by experiencing the world with and through our body, and by reflecting on our encounters with the world [3], [4]. Experiences leave traces in the body as body habits and reaction patterns – posture, mimicry and movements. We acquire mental and bodily attitudes to ourselves, to the world and to other people. Security or insecurity experienced during childhood can result in different body habits and reaction patterns. Kirkengen describes how abuse is inscribed into bodies, and may appear as various disorders, including chronic pain [5]. A continuous “being on guard” attitude may be expressed as holding the breath, tense musculature, and a restricted movement pattern. Body habits are usually unconscious, and they have to be discovered before they can be changed.

A group-based treatment with movement training and discussion for women with chronic muscle pain was developed in primary healthcare.

• The goal was to increase participants’ awareness of their bodies and the connection between personal experiences and bodily habits.

• A narrative approach can show how patients can link events and experiences together, and the significance attributed to the experiences.

• By getting to know their own reactions, vulnerability and strengths in a treatment programme, patients may get an opportunity to change.

Using this as a starting point, a physiotherapist and a doctor developed a group-based treatment programme for women with chronic muscle pain. Experiences in the group prepared the ground to alter bodily habits towards better balance, reduced muscle tension and more freedom when breathing [6]. Participants in previous treatment groups have reported experiences of change during the programme [2], [7], [8]. The treatment programme has been presented in more detail in previous publications [2].

We wanted to learn more about how the change processes were experienced by the participants. We therefore explored individual narratives of participants in the programme as a starting point to understand the process of awareness, including establishment, development and change of attitudes, habits, and bodily practices.

Material and methods

Eight women aged 29 to 56 years completed the programme of a treatment group in 2004. Three women were working full time, four had partial sick leave, and one was being rehabilitated. Issues such as muscle and pain physiology, communication, and how “life leaves its marks on the body” were emphasized in the instruction; and in the group discussions these subjects were linked to personal experiences.

Semi-structured interviews with all participants were conducted after completing the programme, searching for strategies which the women had developed in order to handle their pain and the impact of personal and bodily reflexivity during the treatment programme. Audiotapes were transcribed and systematic text condensation was conducted [9], [10]. The first author coded all transcripts, with the second author joining when negotiating the final categories and their contents.

All the women said that they had benefited from participation in the group, developing strategies for handling their pain [8]. New models for understanding pain and increased confidence in themselves were considered as important. All women talked about change, but the meanings attributed to experiences were individualized. For the case study we present here, Kari's interview was chosen for analysis because it illustrates the development process particularly clearly. This woman's story is not special, but has much in common with the stories of other participants both in this and in previous groups [2], [7], [8].

Narratives are stories where events, actions, or experiences are presented together as seen from the perspective and experiences of the individual [11]. We carried out a narrative analysis of Kari's story to explore experiences the participants may associate with increased personal awareness, and how this can affect their relationship to their surroundings. More specifically, we focus on the events Kari associated with her getting to know herself better. Narrative analysis is a tool for studying temporality (passage of time), plot (experienced coherence), actors (interaction patterns), and reader response (relation between listener and narrator) [12]. Narrative analysis was considered adequate to study change, including temporality as well as experience. Phenomenological perspectives, merging the person and the body as a subjective, experiencing, acting, and meaningful phenomenon, were applied. We emphasized elements in the narrative that show how Kari linked events and experiences, and the significance she attributed to her experiences. First we identified themes (to rely on, to receive and take responsibility, to manage alone, not to brood over things, not to be distracted by unimportant details). Then we looked for coherence, finding connections and patterns in the text. Finally, we developed a version of the story where emphasis is put on this. Below we summarize these findings through a single case, focusing experiences that were reported by several participants in different ways.

Results

“Kari” is a woman in her fifties; she is a widow and has adult children. She has worked doing nursing and care duties all her life and been troubled by pain for many years. Kari is on 50% sick leave, and her employer is trying to find lighter work for her.

Kari said that she had always been strong and managed by herself, and that she had never asked anyone for help. She had always been large and was regarded as a sturdy child – someone who could put up with difficulties. When she and her classmates lined up for a vaccination in primary school, she fainted. This surprised everyone. She thought that her self-reliance was connected with the responsibility she was given for her invalid mother.

When I was 21 years old and just finished training as an auxiliary nurse, my mother developed cancer. Then the others decided that I should stay at home and nurse her. From January to November I had all the responsibility for mother, had to accompany her to and from the hospital, and had to sleep in her room at night because she had so much pain and needed help. After she died, no one had any use for me.

Being asked about her satisfaction with the treatment programme, Kari answered that it was marvellous that anyone was interested in her problems, and that this seldom happened. She described her first encounter with the physiotherapist as a momentous experience.

When I was examined by B [the physiotherapist], she asked me to lie down on the floor. And then she said that I must relax and let the floor accept me and carry me. Then I started to cry. For the first time, there was someone taking responsibility for me.

Kari said that she had never thought about causes or why things had become as they were. She described herself as superficial and attributed this to her restlessness. She was often annoyed by the way the discussion group made such slow progress and looked inside themselves, and thought that the others made far too much of details. She started to reflect on this irritation.

Everyone says that I am so calm. Even when I am under stress, I have always looked very calm; my real feelings just don't come out! I have learnt to close down, if people are angry or annoyed, this has not affected me. I think you have all been too interested in causes … in the group. I think there are buttons to press … I don't know. My interpretation is that there is a lot hidden down there. And I don't know whether one should start pressing buttons.

Participation in the discussion group had started reactions in Kari:

I felt sad almost every time I left the group. Yes, sometimes I felt very restless and sometimes kind of depressed, and sometimes I cried on my way home, without knowing why. There must be things that I should do….

Kari describes how participation in the group had taught her that she should look inwards, instead of doing as she used to, always focusing attention outwards and keeping herself occupied. From her experiences in movement training she said that some exercises were unpleasant. One of the exercises consisted of lying on the floor and feeling the contact made by the different parts of the body with the floor surface.

When we are lying and feeling it on our bodies, I have to go inside myself, I think the unpleasantness comes from there. I have felt that my troubles come from my body; there are so many things there that get in the way. There are so many obstacles between me and the outside, my thighs, bottom and back, that I have difficulty in making contact with the flat surface; I feel that all the fat is what is in my way. Fat protects, they say. When I was lying on the floor, the layer of fat became so obvious; I was forced to try to notice it. It was like pressing on some painful spots. Something seems to be stored inside … which is life. That was probably why I became sad. I have shut off some things. Perhaps they have stored themselves in the layer of fat?

Kari thought that participation in the group had helped her lower her stress – previously she used to walk around as she ate breakfast, now she could sit down calmly to eat. But the unsolved position at work still caused her stress.

Theoretical perspectives

We now proceed to a theoretical level, elaborating our understanding of the narrative content. Phenomenological perspectives help us interpret Kari's story, where she described how she had shut off outside impressions, and kept her feelings and reactions to herself. She described how the layer of fat protected her, and had prevented anyone from getting past it, but at the same time it represented painful spots.

The living body is synonymous with the person and there is nothing “behind” the body [3], [4]. The body is intentional, implying that the body's reaction to a situation is not a reflex, but a purposeful way of reacting. Bodily habits and way of behaving developed by the individual can thus be perceived as actions directed by the body [13]. When experiences are echoed in the body, tension may develop as a reaction to the body's interpretation of its situation.

Kari's story proposes that her body has responded to expectations to be strong and not give up – to tense her muscles, hold her breath, and lock her movements. Her symptoms of pain and stiffness are comprehensible in this perspective. If these reactions have been constantly repeated, Kari may have developed the habit of holding back. She wonders whether it might “be stored in her layer of fat”. A stiff body, a reserved attitude towards receiving and letting anyone come close, and a restricted approach to expressing stress and frustration can be seen as Kari's attitude and behaviour pattern in relation to her surroundings.

Honkasalo writes about how chronic pain can be regarded as an attitude to the world [14]. According to a phenomenological perspective we consider that such an attitude also has a bodily aspect and can be recognized in body posture such as holding the breath, poor balance, and a restricted movement pattern. The attitude can thus be seen as both body posture and mental outlook, and is portrayed by concrete actions [15].

In the training group Kari was able to acknowledge her bodily experiences – what it means to her when she feels sad and restless when she is lying on the floor and has to “feel”. These experiences showed Kari patterns that she associates with previous experiences. She has seen that life events affect her attitude to the world. Expectations about being strong are folded into the body as habits. New experiences may lead to a change in interpretation so that new ways of thinking are created. Once Kari can differentiate better between before and now, it may also be easier for her to change ingrown bodily patterns which are no longer necessary.

The situation is not the same as when these were established. Perhaps being strong and invulnerable has been adequate for facing external demands. But when the demands are less strong, she might change her bodily attitudes towards other people. By increasing the awareness of her own reactions, her vulnerability and her strong side, Kari gains an opportunity to change. Meanings may be re-created when Kari experiences herself in new ways. If Kari should choose to change, becoming less self-sufficient and shut off, she might become more flexible and receptive and perhaps have less pain and stiffness in her body. However, our data and the analysis we chose cannot predict Kari's future development.

Discussion

Possible connections between life experiences and bodily pain

Kari's story provides access to how she creates connections by interpreting her contemporary situation in terms of previous experiences. We are not the first to demonstrate that patients’ understanding of self is crucial for change [16], [17]. Yet, our study has expanded the understanding of change from a phenomenological perspective, where bodily, mental, and social aspects constituted parts of the same process.

Kari's story is not a factual basis in the sense of providing a final solution to causality. We can choose to trust Kari's story where she describes how bodily experiences and reflections in the group started processes inside herself letting her see her habits in a new perspective. Our study supports previous research regarding personal narratives taking place in a continuum between autobiography and myth, where individual and collective experience are merged [18], [19]. Furthermore, our analysis suggests that embodied experiences hold the capacity to reconstruct a “forgotten” world and create new connections [5].

Kari's story tells us about possible connections between life experiences and pain. This story can illustrate how the ideals of being clever and self-reliant and “not giving up” can shape women's lives. This connection is individual – yet individual stories reflect common cultural traits [20]. We chose Kari's story because we recognized so many elements from other stories that justified some general conclusions. This is supported by our theoretical framework, implying that a narrative approach can elucidate phenomenological matters. Embodied experiences and discoveries started off changes in Kari. To be able to change habits and reaction patterns, one must be aware of them. Awareness requires allowing oneself to look for them, and this may involve unpleasantness, as in Kari's case. The change processes may be painful; the outcome is unknown. Not everyone wants to start this type of process; perhaps it will do no good? As therapists, we cannot know whether people benefit from or are able to carry out changes. It is up to people to make their own choice. A therapist with awareness of individual narratives may be able to perceive the core values of the patient better than when universal solutions are sought [21].

Storytelling as interaction

A narrative approach enables the researcher to try to find the meaning that a person gives to her life by telling a story. Different stories can be told about the same event, depending on the context, purpose, and the narrator–listener relationship. In narrative analysis, the story is further transformed, since the listener becomes a co-narrator when the meanings are summarized and elaborated. Kari's story has been developed in this way at least twice – first by sharing it in the group, and then by talking with the interviewer. Any new version will bring with it traces of previous responses. In this interview, the role as co-narrator was probably less important for the story than what had happened in the group over time. We have emphasized story elements related to change, including bodily experiences, self-reflection, and attitude to the surroundings. Such issues appeared recurrently in the stories of all the participants, and were most consistently articulated by Kari. There is no self-evident definition of what is relevant or what is irrelevant in a particular narrative [22]. The choice of what to tell and what to omit lies entirely with the narrator but can be modified by the listener. An interviewer without field knowledge might have difficulty in understanding Kari's accounts of experiences from exercises based on Basal Body Awareness. As group leader, SS was engaged in the treatment programme, knowing the participants she interviewed very closely. Kari's story emerged from this interaction and would not have been the same with someone else. The transferability of our findings is better understood on a conceptual level than as valid for certain populations, in the sense that the ideas concerning potentials for change related to experiences of chronic pain can be applied in a broad range of clinical settings.

So what?

Healthcare providers who want to contribute to change must develop a capacity to perceive somatic discomfort as more than symptoms. A simplified interpretation of possible underlying mechanisms is seldom useful in primary healthcare. A phenomenological perspective may help in understanding the body as ambiguous, that it senses, feels, and experiences, while providing a starting point for reflections on what experiences may mean. Professionals can help patients develop connections between body and verbal language. Reflexivity is created by attributing meaning to conditions and is interpreted as relevant knowledge [15]. Doctors must learn to recognize such knowledge if they are to be able to help.

Acknowledgements

The funding for this study was provided by the Norwegian Foundation for Health and Rehabilitation through the Norwegian Women's Public Health Association.

The study was approved by the Regional Committee for Medical Research Ethics.

The authors know of no potential conflicts of interest.