The good pain patient: a critical evaluation of patients’ self-presentations in specialist pain clinics

ABSTRACT

Established research supports collaborative patient-clinician communication as a means of improving pain management and decreasing opioid use by patients with chronic pain. However, much of this scholarship emphasises clinicians’ capacities to shape and improve communication; limited research investigates patients’ roles in this process. Drawing on 40 ethnographic observations of patient-clinician interactions, clinical spaces and case conferences within one specialist pain clinic in Brisbane, Australia, this paper investigates how and why patients present themselves in particular ways within consultations. Our theoretical lens combines concepts from Goffman on patienthood and stigma with Foucauldian theories of pastoral and disciplinary power. Findings suggest that elements of the clinical environment – namely posters – usher patients towards presenting in what we conceptualise as the ‘good pain patient’ role. In this role, patients demonstrate that they are moral, responsible, and contributing members of society. Yet, such a role is problematic to opening communication, with the role constraining what is socially acceptable for patients with chronic pain to say, do, or feel. In recognising how clinical contexts facilitate problematic good pain patient presentations, this paper directs attention to the spatial and relational nature of implicit clinical expectations and constrained good pain patient presentations.

KEYWORDS:

• Ethnography
• patient-physician relationship
• illness behaviour
• chronic illness and disability

Introduction

A trend of problematic communication has emerged in the context of chronic pain care. Opioids were the primary medical intervention for chronic pain (Buchman et al., 2016). Growing recognition of associated harms has prompted treatment shifts; clinical practice now prioritises exercise or lifestyle-based interventions as first-line interventions (Islam et al., 2016). Rates of opioid mis/use remain high and implementation of provider-targeted initiatives like prescription drug monitoring programs have had limited effects (Mathis et al., 2020). A potentially related trend of problematic communication has emerged; patients are thought to present in manipulative ways, interpreted as opioid-seeking (Matthias et al., 2014). Much of the research on this trend emphasises clinicians’ roles in managing this behaviour through facilitating ‘trust’, ‘empathy’, and ‘patient-centred care’ (Buchman et al., 2016; Fu et al., 2018; Matthias et al., 2014). However, clinician-centric approaches overlook how and why patients seek opioids.

Beyond clinician-centred research, this study seeks to understand how and why patients present themselves in consultations in the ways they do. We employ a broad focus accounting for clinicians’ practices and the wider material clinical environment surrounding chronic pain consultations. In the following paragraphs, we first attend to chronic pain’s complexity, with biomedical conceptualisations implicated in the stigma associated with chronic pain. Second, we present our theoretical framework – combining concepts from Goffman’s dramaturgical work with Foucault’s concepts of power. We then discuss our methods and findings, demonstrating how patients are channelled toward presenting as what we call ‘Good Pain Patients’, showing how – across varied subject positions – the clinical environment implicitly primes such a role.

Pain, biomedicine and stigma

Pain is a complex subjective experience, subject to extended classification (Whelan, 2009). As a field of inquiry, pain is comprised of ‘multiple professional fields and technologies’ (Pryma, 2022, p. 18). The biomedical model emphasises anatomical and physiological causes (Shaw et al., 2009). Following Descartes’ mechanistic model of pain (Bendalow, 2013), physical pain was conceptualised and measured as sensations of harm broadcast through the nervous system communicating danger and healing (Cohen et al., 2021). Acute pain – an immediate psychophysiological response to tissue trauma and inflammation – is often contrasted with chronic pain – pain that continues following recovery (approximately 3 months) with no evolutionary value (Cohen et al., 2021).

Cartesian conceptualisations of pain, which divorce mental and physical states, have been critiqued for overlooking socioemotional and relational aspects of pain (Bendalow, 2013; Fitzgerald, 2020; Melzack, 2005). More recent research acknowledges pain as involving sensory, visual, cognitive, emotional, neural, and stress regulation systems (Fitzgerald, 2020; Melzack, 1999). Others also include a broad range of determinants: personal circumstances, pain beliefs, and other nonmedical and psychosocial factors (Shaw et al., 2009). Such scholarship positions pain as inherently social and intersubjective, with experiences of pain interpreted through pre-constituted social categories and meanings (Morris, 1991).

Extending the biomedical model, new frameworks have been introduced. Moseley’s (2007) interoceptive model of pain, for example, argues that pain is not always commensurate with tissue damage; it is moderated across physical and psychosocial domains. The biopsychosocial model has become the preferred model in chronic pain care as it acknowledges intersecting subjective and physical causes of chronic pain (Koes et al., 2010). Government-supported multi-disciplinary pain clinics have been established to treat complex chronic pain, where a range of specialists – chronic pain specialists, psychiatrists, psychologists, nurses, physiotherapists, and dieticians – work collaboratively to provide comprehensive care and treatment (Sonenberg et al., 2020) that favours active mobility over passive analgesics (Fu et al., 2018).

Despite widespread acknowledgement of chronic pain’s complexity, narrow interpretations continue to dominate clinical practice, care expectations and patient-clinician communication (Mescouto et al., 2022a). Mescouto et al.’s (2022a) critical review of the biopsychosocial model, for instance, suggests many researchers applying the model give only modest attention to psychological and minimal attention to social concerns.

Chronic pain’s complexity, compounded with concerns about opioid abuse, exacerbates the potential for stigma. Many who experience chronic pain lack the visible physiological indicators used in social and medical interactions to legitimise experiences of illness (Kempner, 2014; Paul-Savoie et al., 2018). The absence of a clear pathoanatomical diagnosis can result in stigmatisation, prompting questions about the authenticity of the patient’s status (Buchman et al., 2016). With limited congruity between patients’ subjective experience of pain and objective medical findings, there is potential for professionals to doubt the legitimacy of pain, informally question the motives underlying patient presentations of pain and assign stigma (Paul-Savoie et al., 2018).

There is a long history within health social sciences of examining how (potentially stigmatising) consultations are negotiated between clinicians and patients. Early scholarship showed how stigmatising judgements regarding a patients’ deservingness of treatment shape treatment decision-making (Jeffery, 1979). Recently, it has been argued that the stigma associated with opioid use in the USA and the often-unclear aetiology of low back pain underpin a trend towards the ‘surgicalization of back pain’ (p. 58) – a navigation that allows patients to conform to moralised neoliberal expectations of having a ‘productive body’ (p. 68) that is free from addiction (Crowley-Matoka, 2020). Political and affective economies of care (Fitzgerald, 2020; Olson, 2022) ideologically inform such judgements. In contrast to political arrangements where interdependence and care delivered by the state is the expectation, neoliberalism is implicated in expectations that patients – or in Mol’s (2008) terms ‘health citizens’ – take responsibility for their wellbeing through healthy choices. This process of positioning individuals as culpable – in an era where health has become a moral imperative – has been a sustained focus of medical sociology (Lupton, 2012; Petersen & Bunton, 1997).

Foregrounding the political backdrop to patient-clinician interactions helps theorise how patients with pain – but without a clear pathoanatomical explanation – are channelled towards demonstrating their moral status in clinical interactions. The stigma associated with opioid use is well-documented (Ezell et al., 2021), inflecting clinicians’ perceptions. ‘Deserving pain patients’ are seen to be contributing, high-functioning ‘health citizens’ who use opioids as a last resort; ‘illegitimate care seekers’ are those whose poor choices have exacerbated their pain making them less deserving of opioids (Mol, 2008; Nickerson, 2016). Holloway and colleagues (2009), for instance, found patients with chronic pain manage stigma in their clinical interactions by presenting as morally sound and credible witnesses to their pain. Furthermore, Henry and Matthias (2018) found patients present as stoic, barely managing pain, and as responsible analgesic users who are trustworthy and therefore can be prescribed more opioids.

Scholarship on problematic patient-clinician communication in the context of chronic pain and stigma suggests chronic pain patients strive to present favourably to clinicians (Mathis et al., 2020; Matthias et al., 2014). Implications encourage clinicians to foster trust and empathy in their practices to improve communication (Buchman et al., 2016; Fu et al., 2018). Although such practices are important, they may be short-sighted, foregrounding clinicians while overshadowing patients and clinical settings. This paper offers a theory-rich, critical analysis of pain patients’ presentations. Positioning this study in relation to the theoretical contributions of Goffman and Foucault, we conceptualise presentations of pain as part of a ‘good pain patient’ role, a term we offer from this study to denote patients’ demonstrations of character – morally sound, responsible, and contributing members of society – in relation to a clinic’s expectations. Importantly, we do not seek to problematise the good pain patient role as a means through which patients seek opioids or other support, but instead as a tool patients use to navigate potentially stigmatising discourse in the clinic. Crucially, we recognise the influence of the clinical context in facilitating a good pain patient role.

Goffman and Foucault: A cross-cutting theoretical approach

A wealth of research demonstrates the stigma associated with chronic pain and opioid use (e.g. Bean et al., 2022; McCradden et al., 2019). Adding to this scholarship, we adopt Goffman’s (1968) dramaturgical framework to understand the micro-interactional processes and practices that define clinical communication and the production of stigma within the clinic. Drawing on Goffman’s dramaturgical concepts of patienthood and stigma, this study asks: How do pain patients present themselves and their pain? To avoid a narrow application of stigma as positioned within the individual, we draw on Foucault’s concepts of power.

Stigma refers to an attribute or behaviour that discredits an individual as polluted, deviant or morally suspect (Gabe et al., 2004). In healthcare contexts, patients and clinicians are thought to perform roles. Expectations and interactions – not just the physical attributes or capabilities of the individual – bring stigmatised identities into being (Goffman, 1968). Yet, scholarship on chronic pain stigma focuses almost exclusively on people experiencing stigma (McCradden et al., 2019), rather than the ideological and political systems producing this stigma (Bean et al., 2022).

Recent sociological scholarship has critiqued applications of Goffman’s work for failing to account for structural mechanisms producing stigma (Tyler, 2018). Link and Phelan (2014), for instance, argue that power and stigma are intertwined at all interaction levels, recognising the powerful’s top-down interests in stigmatisation. Tyler and Slater (2018, p. 721) similarly argue purely micro-interactional approaches to stigma overlook socio-political questions, such as ‘how stigma is used by individuals, communities, and the state to produce and reproduce inequality’. In short, without the context of power, stigma loses its utility (Link & Phelan, 2001). Thus, in this study, we conceptualise stigma as discrediting attributes reproduced and managed interactionally and institutionally, reflecting broader ideological power inequities.

To foreground power, we draw on Foucault’s (1977, 1982) concepts of ‘pastoral power’ and ‘disciplinary power’. ‘Pastoral power’ refers to power traditionally exercised by priests over members of their congregation in encouraging confession and truth-telling – a practice that has ‘spread its effects far and wide’ (Foucault, 1981). As a form of power defined by its emphasis on personal salvation, it is individually motivated and governed because it is a component of an individual’s construction of identity (Martin & Waring, 2018). Disciplinary power refers to the comparison of an individual’s actions to the norm, a comparison which goads the individual to strive to adhere to that norm. Through such disciplinary strategies, individuals are ‘subjugated and subordinated to an order’ (Lilja & Vinthagen, 2014, p. 109).

These concepts help demonstrate that medical power is enforced not by ‘pounding them into submission’, but ‘inciting them to speak’ in a way that encourages patients to take responsibility for their health (Silverman, 1987, p. 226). Following Cook and Brunton (2015), who employ ‘pastoral power’ to foreground the ethical work and power relations complicating patient-centred care in gynaecology, we use these concepts to recognise the power circulating through discourse, norms and subjectivities, informing another research question: How does the clinical context shape patients’ expected presentations of pain related to opioid prescription?

Thus, we draw on Goffman’s dramaturgical approach and Foucault’s concepts of pastoral and disciplinary power to appreciate medical power (macro), opioid-related stigma and its affects in the (micro) context of patient-clinician communication. This situates our study within a history of scholarship emphasising the intertwinement of stigma and power, realised through the performance of everyday roles and identities. Shifting power from the periphery to the centre of our analysis, Foucault’s work enables us to attend to power-laden discourses shaping patients’ and clinicians’ interactional presentations.

Methods

This paper draws from a 17-month critical reflexive ethnographic study investigating the humanistic (Fortuna et al., 2022) aspects of low back pain (LBP) care across two clinical sites (Costa et al., 2023; Dillon et al., 2023; Mescouto et al., 2022b; Mescouto et al., 2023; Mescouto et al., 2024). Ethnography, which aligns with a social-constructivist appreciation of social reality as relativist and co-constructed, was selected for its capacity to attend to the socio-cultural forces shaping practices (Lincoln et al., 2013). A critical reflexive ethnography invites participants to review, co-analyse, reflect on, and attend to ethnographic findings. Building on Lassiter’s (2005) collaborative ethnography, such an approach foregrounds the researcher-researched relationship, extending the constructivist tradition to prioritise participatory values of co-constructing practical knowledge with and for the transformative benefit of the researched (Lincoln et al., 2013). Beyond a reflexive approach which foregrounds the research team’s positioning as social science and clinician researchers (Braun & Clarke, 2019), our critical reflexive ethnography involved presenting key findings and theories back to clinician-participants and engaging clinician-participants in the re-imagination and revision of their practices. Setchell et al. (2018) applied a similar methodology, suggesting that critical reflexive ethnography – through its collaborative processes – is positioned to make beneficial recommendations for local clinical practice, with possible transferability.

For this paper, we used two data sources from the broader project: (1) observational field notes of LBP patient-clinician consultations at one pain clinic, and (2) transcripts of clinician dialogues – multidisciplinary analysis workshops held for researchers and clinicians at the observed clinic to reflect on the analysis of the clinic’s practices. Observations were collected by three PhD candidates (two physiotherapists and one osteopath) and two Research Assistants (a physiotherapist and education researcher) trained in critical reflexive ethnography. The researchers wrote field notes about verbal and non-verbal aspects of patient-clinician consultations, multidisciplinary team meetings or case conferences, and the clinical environment. Although researchers tried not to partake in the consultations or meetings and sat quietly in the corner of the rooms, participants would eventually interact or acknowledge the researchers’ presence. Clinician dialogues and research team analysis meetings were a way of working reflexively and collaboratively with stakeholders and the broader research team. For this paper, clinician dialogues are valued as a secondary source of data in which clinicians were able to confirm and extend researcher analysis, enabling the research team to iteratively refine the project’s scope and depth.

Sample characteristics

This study draws from a pool of 40 observations at one specialist pain clinic – of patient-clinician interactions (n = 32), the clinic’s environment (n = 5) and case conferences (n = 3). After reviewing the dataset, 12 observations were selected for in-depth analysis and prioritisation in this paper, due to the prevalence of opioid-related discussions. Analysis of the remaining observations is prioritised in published studies (Costa et al., 2023; Dillon et al., 2023; Mescouto et al., 2022b; Mescouto et al., 2023; Mescouto et al., 2024). Seven of the observations prioritised for this study are of patient-clinician consultations (two involving multiple clinicians); the remaining 5 observations are of the clinical space and treating rooms, or made during daily group case conferences. Participating patients were predominantly female, ranging in age from 44 to 76 (see table 1). Involved clinicians represented a range of disciplines: physiotherapy (n = 2), psychology (n = 1), psychiatry (n = 1), medicine (n = 3), specialist pain care in medicine (2 specialists, 1 registrar).

Table 1. Demographic and contextual information on the seven patient-clinician consultation observations.

Patient Pseudonym	Clinician Pseudonym (Gender)	Patient Age	Patient Gender	Patient-Clinician Relationship Status	Comments
ZaraPatient	OmarDoctor (M)	46	F	Existing
AnnaPatient	NoahDoctor (M)	65	F	Existing	AnnaPatient’s caregiver Louise was in attendance
MilaPatient	RubyPsychologist (F) OscarDoctor (M) PiperPhysio (F) NoahDoctor (M)	44	F	First Consultation	One-on-one consultations followed by a joint multi-disciplinary treatment consultation with NoahDoctor advising
MaryPatient	BreePsychiatrist (F)	76	F	First Consultation
JohnPatient	SarahPhysio (F)	64	M	Existing
SarahPatient	PainDrJohn (M)	71	F	First Consultation	SarahPatient’s daughter Emily was in attendance
JDPatient	AmySpecial (F) (Pain Specialist) OscarDoctor (M) StephenSpecial (M) (Pain Specialist)	67	M	Existing	A single consultation with all three clinicians in attendance

Analytic approach

During analysis, we employed a reflexive thematic approach influenced by post-qualitative inquiry. Following Braun and Clarke (2019), reflexive thematic analysis involves researchers drawing on experiences and expertise to identify meaning-based patterns referred to as themes. As such, researcher subjectivity is a valued resource. This paper conveys the analysis of a research team with specialist knowledge in sociology, psychology, physiotherapy, and clinical practice. Following post-qualitative scholars, theory was also employed as an analytic resource. Proponents of post-qualitative inquiry argue that standardisation practices aiming to increase methodological ‘rigour’ hamper qualitative research’s capacity (St. Pierre, 2018). Instead, they urge ‘thinking with theory’ (Mazzei, 2021). Shifting away from ‘methodological fetishism’ (Olson et al., 2020, p. 158), while still retaining the value of method in bringing ‘concept and problem together’ (Mazzei, 2021, p. 198), we fostered knowledge production driven by active theoretical engagement using concepts from Goffman and Foucault.

Procedurally, adopting a reflexive thematic approach to analysis, inspired by post-qualitative inquiry, involved open, but theory-informed coding. Following inductive engagement with the data, we identified relevant literature (e.g. Goffman), allowing us to refine the study’s scope and intent. During the reflexive team analysis sessions we attended to posters portraying individuals as responsible for their pain and their connection to certain social behaviours. This prompted us to reorient our analysis to better attend to moral expectations, truth-telling and power. Thus, we widened our theoretical scope to include Foucault’s concepts. Using both Foucault and Goffman to ‘read’ and organise our data, drew our attention to power’s embeddedness within structures, processes, and practices at the clinic (Petersen & Bunton, 1997), while in turn emphasising the way patient presentations are a product of, and response to, clinical environments (Goffman, 1959).

Ethical considerations

The broader reflexive ethnography of LBP at two clinics, in which this study is embedded, received ethical approval from both the relevant university Human Research Ethics Committee (approval 2019002446) and hospital ethics committee (HREC/2019/QMS/54704).

Findings

Overall, findings – presented here using pseudonyms – suggest that posters within clinics communicate discursive expectations that patients take responsibility for their pain, continue their usual roles and avoid opioids. We examine inflections of such expectations in patients’ presentations as ‘good pain patients,’ drawing on Goffman’s presentation of self and Foucault’s concepts of pastoral and disciplinary power, invoking interpretation intermittently from empirical and theoretical scholarship. We argue that this dynamic impedes health communication, constraining patients’ in divulging challenges, asking questions or actively directing their care.

Posters in the clinic: Morality on display

Clinical spaces often feature evenly spaced waiting chairs, muted daytime TV, and informational posters. Such posters featured within our field notes. This unassuming décor can be reimagined within the context of Foucault’s concepts as a means through which power-laden discourses are embedded in clinical spaces (Jones, 2018).

Many posters portrayed infographics targeting chronic pain: ranging from exercise and diet advice to physiotherapy and best practice approaches to treatment. They shared a consistent theme of ideal health behaviour, prompting further consideration. Notable health promotion posters are described in the following observations.

A poster was fixed to the wall near one of the doors that said ‘Exercise Really is Medicine’ … Nearby was another poster of unknown origin declaring the ‘15 Benefits of Outdoor Exercise’.

Finally, tucked away up near ceiling height above the large treatment table was a poster entitled ‘Eat for Health’ … . concerning food choices and nutrition … 

These posters promoted physical activity and nutrition in treating pain. Yet, a core implied message was that the onus is on patients to manage their pain, as noted in an observation of the exercise room:

I wondered how patients took the messages on the wall as they seemed to focus on the patient’s responsibility for their pain and that exercise is the answer. I felt somewhat confused by this, as I do not have the impression that the site provides much in the way of exercise-based treatment.

Attending to the researcher’s confusion in a research team analysis meeting prompted reflection on the posters’ implicit messages. In consideration of the limited capacity for on-site exercise-based treatment, encouraging patients to take responsibility for their treatment through diet and exercise would communicate, even before their consultation begins, that productive pain patient behaviour involves demonstrating proactive attitudes towards diet and exercise. Within a broader understanding of stigmatising portrayals of pain patients as malingering and illegitimate, these posters – with titles like ‘stand on your own two feet’ or ‘eat for health’ – activate moral dimensions of physicality and responsibility, defining patient expectations (Holloway et al., 2009; Nickerson, 2016). Thus, the posters implicitly communicate that active engagement with these moral aspects is required in patient consultations.

One poster, displayed in a consultation room within the clinic, stood out: The Neuro Orthopaedic Institute of Australia’s ‘Road to Recovery’ (Butler & Moseley, 2016). With its bifurcated and stylised road with clearly discouraged turns (e.g. ‘Mt Nowhere’; ‘Festival of Catastrophisation’; ‘Lake Avoidance’; ‘Valley of disuse depression and disability’) and supported shortcuts (e.g. ‘Opportunity Bypass’; ‘Pacing & Knowledge Staircase’) for patients with pain after experiencing injury, the poster was striking because of its clearly stigmatising pain-management discourse. It provides an extreme, yet clear, demonstration of the dichotomous separation between a ‘good’ and ‘bad’ pain patient, and the actions and attitude expected of each. An illustration of a man with a racquet, despite one arm being in a sling, on the ‘Road to Recovery’ depicts ‘good’ patients as physically active. A sketch of a woman’s face pointing with one hand towards pills and the other towards her mouth – between ‘Fearville’ and ‘Cortisol Corner’ on the road that does not lead to recovery – depicts ‘bad’ patients as reliant on analgesics (Butler & Moseley, 2016). To follow the ‘Road to Recovery’, patients must demonstrate comprehension (‘Comprehension highway’), maintain bravery (‘Bravery Chicane’), and acknowledge the many challenges to recovery from chronic pain. In contrast, the circular path that does not lead to recovery features the use of pharmaceuticals, experiences of anxiety and depression, overuse of healthcare, and stagnation: ‘bad’ patient behaviours. The ‘Road to Recovery’ explicitly demonstrated how discourses related to physicality and medication serve to moralise, stigmatising certain actions and identities.

Crucially, the poster frames actions, experiences, and emotions as patient choices. The absence of health professionals (other than the ‘Sea of Endless Professionals’), the analogous depiction of patients’ pain management as a map or road, imply the patients’ agency and responsibility in choosing a direction of travel and their ability to plot their route and destination. Though the roads seem to inevitably lead through these destinations, the posters’ terminology of ‘Anxiety Town’, ‘Festival of Catastrophisation’, or ‘Lake of Avoidance’ situates these emotions as places that patients choose to traverse.

Shifting responsibility to patients, framing behaviour as a choice, constrains what is acceptable for pain patients to say, think or do in consultations. By casting pain and emotions as choices, patients’ perceived liberty to express negative emotions, attitudes, or experiences is constrained by fears that such presentations would be attributed to their inherently ‘difficult’ character. Valorising ‘bravery’ and ‘comprehension’ on the road to recovery suggests it is a patient’s choice to demonstrate these behaviours. Perceived deficits could therefore be cast as wilful deviations, undermining opportunities for patients to seek clarification on aspects of their interactions that they don’t fully comprehend and engage with or influence clinical practices.

The posters’ style and format are also significant. The authoritative tone and cartoonish style of many of the posters infer a condescending tone. Whilst this is most visible in the ‘Road to Recovery’, it was also noted in other posters:

Another poster from Health and Community Care was titled ‘Stand on your own 2 Feet’; it was quite whimsical and consisted of cartoons of a ‘granny’ avoiding fall and trip hazards.

Such posters cast patients as simplistic learners capable of only a basic understanding of medical knowledge, while simultaneously communicating expectations of individual responsibility and subtly positioning patients as suppliant recipients.

Responsible and active members of society

The expectations implicitly communicated through posters informed our interpretation of patients’ demonstrations of physical activity. Although direct reference to posters was absent, expectations were common in our observations, featuring patients emphasising their efforts to be independent and proactive. Such demonstrations communicated more than the frequency of their exercise; they communicated a patient’s knowledge of expected behaviour. For example, in the following consultation with NoahDoctor, AnnaPatient places specific emphasis on her independence in struggling to maintain physical activity.

NoahDoctor comes to the reception and stops right in front of the lady who was groaning. He says: ‘I would normally ask you how you are doing but I think I know the answer so I will just start with a “Good morning”'. Anna looks at him and starts to shuffle her pelvis forward in an attempt to get into a better position to get up off the chair. NoahDoctor then says: ‘I would normally offer help but I know that you won’t accept it … '. The lady who was accompanying her didn’t attempt to help either. Anna doesn’t say anything and attempts to get up – no success on her first attempt. She tries again and manages to get up by herself.

They all start to walk to the room. Anna makes a joke about the fact that she walks very slowly – ‘I will catch you later'.

As NoahDoctor’s first utterance suggests, he has been seeing AnnaPatient for some time. Despite her difficulty to stand unaided, AnnaPatient does not ask for assistance. She subtly draws attention to the severity of her pain with her joke about her slow walking speed. Here, Anna demonstrates to NoahDoctor that she is in pain yet, is proactively approaching the impact of chronic pain on her life and her engagement with treatment. Later in the consultation AnnaPatient confesses the burden of her chronic pain and seeming futility of her current treatment. However, as we discussed in our analysis meeting with clinicians, if AnnaPatient feels comfortable in verbalising the extent of her pain, what purpose is served by these displays of independence? This prompted us to further question why patients emphasise their proactivity and physicality in interactions with clinicians.

In another observation, MilaPatient displays her sound moral character. Our observations of MilaPatient occurred during her first visit to the clinic where a multidisciplinary intake was completed: she was seen in separate consultations by a doctor, psychologist, and physiotherapist. Her first appointment was with RubyPsychologist:

RubyPsychologist asked about how Mila spent her time, and Mila said again that she tried to be as active as she could. ‘If I can’t, I will do more damage,' Mila answered, and then added: ‘I’m trying to be responsible.' … It looked like it was very important for Mila to mention she was always moving.

Here, MilaPatient described her attempts to be physically active and her eagerness to exercise despite severe pain. MilaPatient demonstrates her awareness of ‘good’ or ‘bad’ behaviour regarding exercise frequency, and her responsibility to be constantly moving. Interestingly, in noticing the correct behaviour and referencing her attempt to maintain frequent exercise, MilaPatient’s comments might also serve to demonstrate a capacity for self-regulating her behaviour to conform with expected patient behaviours.

In a later interaction between MilaPatient and OscarDoctor, MilaPatient’s discussion of daily routine and personal life potentially reinforced a narrative of good and responsible pain patient characteristics. In this interaction, OscarDoctor discussed the importance of movement and MilaPatient described how her role as a mother and employee would not allow prolonged inactivity.

OscarDoctor mentioned that it was important to continue to do things, because feeling pain was not the same as damage. ‘I try not to sit around,’ Mila said, and mentioned that even if she wanted to, taking care of 3 kids and having 2 jobs wouldn’t let her be still. They laughed … 

Here MilaPatient underscores her contributing and active lifestyle. Interestingly, MilaPatient referred to her mother and employee roles in all three multi-disciplinary consultations that day. Why did these roles warrant such repetition? This could just be important to her identity. However, given the expectations non-verbally communicated through posters and verbally communicated by OscarDoctor, we interpreted this repetition as MilaPatient indirectly demonstrating that she is a high-functioning and contributing member of society: qualities which might counteract stigma surrounding chronic pain. Nickerson (2016) suggests patients are often framed as either ‘legitimate pain patients’ or ‘illegitimate care seekers’ based on their deservingness of opioid treatment. In this context, OscarDoctor’s comment about the importance of ‘doing things’ might be seen as an inquiry into MilaPatient’s alignment with expected or stigmatised attitudes: a prompt to confess one’s transgressions against or alignment to the dominant pain discourse (Foucault, 1981). Similarly, MilaPatient’s references to her status as mother and employee could be interpreted as establishing her deservingness of care.

Patients’ demonstrations of their alignment with expected values were subtle. However, patients’ relative consistency in portraying themselves as responsible, active, and contributing members of society suggests their shared understanding of what it is to be a good pain patient. The extracts explored above begin to demonstrate the nuanced means by which patients communicated these characteristics. The consistency of these narratives – despite differences in age, gender and employment status – prompted us to elevate the good pain patient presentation into a distinct concept. Whilst communication of good pain patient role alignment was indirect, as a concept, it encompasses the myriad ways patients demonstrate their responsibility, alignment with expectations and deservingness of care. Importantly, we frame this good pain patient role as both a culturally informed presentation and a performance of power and supplication between clinicians and patients.

Supplicants to medical authority

Researchers noted that patients were encouraged to demonstrate their involvement and agency in their treatment, yet there were several moments in which patient engagement promoted suppliance on medical authority. Patients were asked questions about satisfaction with treatment, yet this was done in ways that failed to facilitate full engagement. MaryPatient’s consultation with BreePsychiatrist offers an example. MaryPatient had been referred by her GP to see a psychiatrist to review her pain medication. Yet, she did not seem to fully understand the purpose of her visit and stated as much when asked by BreePsychiatrist. Throughout the consultation, MaryPatient displayed hesitation regarding the use of pain medication; the consultation focussed on her challenges in managing pain, and her support and coping. The following excerpt from the end of her consultation noticeably departs from this trend:

‘Is there something else you would like to talk about today, MaryPatient?' BreePsychiatrist asked. MaryPatient hesitated for a moment and mentioned that a pain medication would be great. BreePsychiatrist said something about a pain doctor and MaryPatient’s GP … BreePsychiatrist also asked about some physiotherapy sessions that MaryPatient had in the past. MaryPatient said that she used to see a physio, and she felt very good afterwards.

Here, we note the incongruence of MaryPatient’s request for medication. One interpretation could be that she waited to request medication, despite previously decrying the potential harms of pharmaceutical interventions, because her interest in a prescription was only moderate. Another is that throughout the consultation, MaryPatient had been complying with good pain patient expectations and it is only at the end of her consultation – after she has established her good pain patient status – that she feels comfortable deviating. The significance of this moment for MaryPatient supports the latter interpretation. This is the only time in the consultation where MaryPatient is asked an open question and is able to directly determine the course of the consultation. We highlight this moment – not to question the appropriateness of treatment decided upon by BreePsychiatrist – to point to the probable strength of the good pain patient discursive expectations hindering MaryPatient’s opportunities to engage in and direct conversations regarding treatment.

A limited capacity to respond to questions openly is evidenced in MilaPatient’s consultation with PiperPhysio. MilaPatient is asked about treatment options but is constrained in her capacity to respond:

PiperPhysio explained to Mila that because of her symptoms and her profile … the clinic usually ran a group to help people understand their pain and the things they can do to help them self-manage. … ‘Would you be interested?’ PiperPhysio asked. Mila said she was [Although I was not sure if she was very excited about that. Mila’s facial expression and body language seemed to demonstrate that she was willing to try different things, but she was not very convinced about this approach …].

Given her non-verbal communication, it was evident that MilaPatient did not view the program favourably. Yet, when asked, she agreed to participate. As with MaryPatient’s consultation, MilaPatient shows limited capacity in engaging in an open discussion about treatment without endangering her presentation as an agreeable and responsible good pain patient.

What is striking across these two interactions is the subtle constraints limiting how patients can pose or respond to questions. In both excerpts’ patients are channelled into a patient role, encouraged to tacitly agree with clinicians’ recommendations and given limited opportunities to influence the course of their care. Given their limited capacity to openly pose or respond to questions, patient presentations become an important mode of communication; good pain patient behaviour becomes a primary means of demonstrating one’s deservingness of care and suitability for greater control over their treatment.

Medication management

Yet, not all requests within our analysis were so constrained. In sharp contrast to the hesitation in discussing pain medication depicted above, JDPatient openly implored his specialist for pain medication.

JDPatient says ‘I’m begging you to help me doctor. I can’t stand it anymore.’ AmySpecial responds ‘mm-hmmm, 1200 mg p.d. gabapentin? That’s a high dose?' She then enquires of JDPatient. ‘Lyrica, have you tried it?' ‘Didn’t work' JDPatient responds. AmySpecial then asks ‘mm-hmm … . 90 mg Cymbalta. Are you on any sleeping tablets?' At this point, JDPatient rummages in his backpack that sat at his feet until now and brings out a printed list that he says has all the medicines he is taking. From a distance it looks like most of the A4 page is printed on in 2 columns … 

Although JDPatient’s blatant request appears to transcend the discursive constraints of the good pain patient role, his 1-page stocktake of medications signifies an implicit recognition of the clinician’s authority regarding treatment, JDpatient’s compliance to medical prescribing, responsibility and adherence to good pain patient expectations. We foreground medication management – not to question the need for clinician oversight – to draw attention to the practices and processes within the clinic that channel patients towards good pain patient presentations.

In sum, patients managed presentations within the clinic to comply with normative expectations or risked being labelled and treated as difficult. Posters offered a clear example from the material environment of discourses of morality, responsibility, and choice embedded in the clinical space, offering a backdrop to analysing how the clinical environment subtly channels patients towards good pain patient presentations. Whilst the topics shifted in consultations from physical activity to paid work, patients negotiated these topics in ways that reinforced their status as good pain patients: demonstrating their character as responsible, active, and morally sound patients. Patients had limited opportunities to deviate from the expected good pain patient role. The implicit power-laden contours of the clinic channelled patients towards good pain patient presentations.

Discussion and conclusion

Health communication scholarship advises clinicians to be vigilant against manipulative opioid-seeking behaviour (Islam et al., 2016) by adopting patient-centred approaches that foster trust and empathy (Buchman et al., 2016; Matthias et al., 2014). Such approaches fail to recognise the situated and discursive dimensions of patient-clinician interactions within chronic pain care. Drawing on an analysis of ethnographic observations at one multi-disciplinary pain clinic, this research demonstrates that clinical environments implicitly define what it means to be a good pain patient, priming patients to present as productive and active pain patients. Engagement with concepts from Goffman and Foucault prompted recognition that clinical (and broader social) environments discursively promote patient compliance that affirms patients’ expectations of stigma. In this final section, we explicate the main contributions of this paper – the concept of the good pain patient – demonstrating its utility, and encouraging attention to nonverbal stigmatising discourses within material environments (e.g., posters).

In past research, when patients have been portrayed favourably to clinicians it has been interpreted as deceptive; those deviating from standard expectations have been characterised as ‘difficult pain patients’ (Henry & Matthias, 2018; Mathis et al., 2020). Within this framing, clinicians are depicted as subtly sorting through manipulative behaviour to arrive at accurate diagnoses, or struggling to redirect and manage patients’ difficult behaviours in requesting opioids without escalating conflict (Henry et al., 2018). These understandings, however, are underpinned by an assumption that manipulative or difficult patient behaviour is motivated by the attainment of opioids. Whilst this may be partially apt, our findings support critical scholarship suggesting attempts to present favourably can also be understood as efforts to achieve legitimacy (Crowley-Matoka, 2020; Toye et al., 2013) and responses to stigmatising discourse (Lupton, 2012), highlighting how such discourses are embedded within nonverbal communication within the clinic’s material environment. This aligns with calls to recognise ‘the agency of nonhumans and objects’ and their importance to health practice (Fraser et al., 2018, p. 65). The focus of much previous literature has been to improve communication with ‘difficult’ pain patients; the good pain patient role expands the scope of understanding to consider why – discursively – this behaviour occurs.

In examining themes comprising the good pain patient role, it is evident they are reflections of broader social stigmas. Notably, ascriptions of ‘deservingness’ and ‘legitimacy’ often arise in discussions of patients with chronic pain and opioid use (Crowley-Matoka, 2020), with research demonstrating the discrediting and harmful impact of stigma experienced by patients suffering from illnesses that have limited outward visibility (Holloway et al., 2009; Paul-Savoie et al., 2018). Indeed, attempts to prove legitimacy may exacerbate pain through negative experiences with the healthcare system (Toye et al., 2013). Embedded in the ‘legitimate’ pain patient identity – reflecting neoliberal responsibilisation rhetoric (Lupton, 2012) and associated expectations of productivity (Crowley-Matoka, 2020) – are notions that it is the patient’s responsibility to manage their illness through lifestyle choices and a proactive disposition (Nickerson, 2016). Such rhetoric was implicit within informational posters within our analysis, discouraging opioid use, encouraging exercise and community engagement – ultimately reinforcing individualistic stigmatising understandings of what it means to be a good or bad pain patient.

Foucault’s concept of disciplinary power helps us consider these posters, how power is enacted by encouraging patients to speak in particular ways, and that the consequences of such power relations are not lessened by their subtlety (Lilja & Vinthagen, 2014; Martin & Waring, 2018). Drawing on scholarship that positions this power as embedded within political and affective economies of care (Fitzgerald, 2020; Lupton, 2012; Mol, 2008; Olson, 2022; Plage & Olson, 2021) helps us see how posters implicitly held patients accountable for their pain. Using Mol’s (2008) distinction between logics of care and choice – with the latter underpinning neoliberal healthcare rhetoric – posters can be seen to essentialise patient choices as counter-/productive behaviours affecting chronic pain treatment outcomes. Here, morality and choice intersect, encouraging a shift in responsibility for chronic pain from care provider to patient (Lupton, 2012). Although the posters are often based on revised theories of pain with scopes that expand understandings of pain beyond the somatic and psychological (Butler & Moseley, 2016; Moseley, 2007), in application the discourses of choice and responsibility in the posters clearly encourage patients to demonstrate their status as responsible and legitimate patients.

The expectations of patient responsibility conveyed in posters were reflected in patients’ performances as good pain patients. In the confessional context of doctor-patient interactions (Mayes, 2009), patients professed to clinicians their status as a ‘good person’ (Toye et al., 2013) and active member of society by discussing their work, or aspirations to be physically active and independent. Drawing on theorisation of responsibilisation, these presentations can be understood – not as deception – but as compliance with medical authority and neoliberal rhetoric (Lupton, 2012).

The concept of the good pain patient role and its prominence throughout our observations adds to this scholarship. It demonstrates the myriad ways patient responsibilisation occurs in a specialist chronic pain clinic while asking how discourses of care, stigma and deservingness may intersect with other identity positions (e.g. gender, class and race). Importantly, we are not suggesting the good pain patient encompasses a universal script; it is a presentation embedded within a patient’s (and their clinician’s) social positioning and current moral concerns (e.g. neoliberalism, anti-addiction, productivity). This contribution is particularly salient in the context of research like that of Buchman et al. (2016), which suggests communication in chronic pain consultations could benefit from a greater equilibrium of patient-clinician responsibility over treatment decision making. Whilst the intent of such research is to promote more open discussion, fuller appreciation is needed of how discourses within the clinic and beyond constrain patients through expectations of the good pain patient role. Indeed, if patient involvement in treatment decision making is broadened without first attending to the stigmatising discourse of clinics promoting the good pain patient role, there is potential for clinical practices to further constrain patient engagement whilst functioning under the guise of patient empowerment (Pluut, 2016). As Mayes (2009, p. 483) argues, ‘while patient-centred communication frees the patient from particular aspects of medical power, it also introduces the patient to new power relations.’ The good pain patient role foregrounds the pastoral and disciplinary power of these clinical procedures, offering a framework for identifying and disrupting clinical practices that promote patient responsibilisation through problematic expectations.

An inherent difficulty of attending to such stigmatising responsibilitation is that it is (re)produced by millions of people acting within the implicit rules of a given discipline or institution, meaning there is no individual actor to be held accountable (Kröner & Beedholm, 2019). Recent sociological research, however, does suggest the importance of organisational goals to in-patient clinical interactions and medical decision-making in the context of opioids (Brewer, 2020). This study responds to calls for strategies to improve care (Toye et al., 2013) and assists clinicians in examining their practices (Kröner & Beedholm, 2019), by offering a conceptual tool for identifying and unpacking stigmatising discourse embedded in clinical environments. Posters featured heavily in our observations; the construct of the good pain patient draws attention to how material environments, as well as confessional interactions and clinical language, converge to reinforce a discourse within the clinic and discipline patients to strive for a particular presentation. The good pain patient’s utility is in enabling stakeholders to understand, recognise, and interrupt these implicit power-laden practices.

In conclusion, our study reveals that independence, responsibility and moral deservingness weigh heavily in how patients and providers discuss and address chronic pain and prescription opioid use. Our analysis adds to considerations of patient-centred communication within chronic pain; discourses embedded within clinical environments predispose patient presentations, constraining communication. We suggest moving away from an individualistic and clinician-centric focus on mitigating manipulative behaviour, towards reflection on discourses of patient choice and morality within clinics (including non-human elements such as posters) to foster more collaborative and open approaches to pain management and communication. Our research supports a shift away from a focus on opioids and deception towards questioning why such conversations are problematic. In providing the concept of the ‘good pain patient’ our research further enables researchers and clinicians to reflect on patient expectations to present in certain ways and how these normative presentations stem from discourses reinforced within clinical environments.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.

Additional information

Funding

This work was supported by National Health and Medical Research Council: [Grant Number APP1157199].