The experience of co-morbidity: an interpretative phenomenological analysis: living with chronic ...

214 Pages·2017·9.43 MB·English

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Williams,Samantha(2018)Theexperienceofco-morbidity: aninterpretativephenomenological
analysis: living with chronic pain and traumatic stress. DProf thesis, Middlesex University /
Metanoia Institute.
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The Experience of Co-Morbidity: An Interpretative
Phenomenological Analysis: Living with Chronic Pain and
Traumatic Stress

Samantha Williams

Middlesex University and Metanoia Institute
Doctor of Counselling Psychology and Psychotherapy by
Professional Studies

2017
CONTENTS

Page
Acknowledgements

Abstract 1

Chapter 1 – Introduction 2-10

1.1 Research Question 4
1.2 Background and Rationale 4
1.3 Definition of Terms 7
1.3.1 Chronic Pain 7
1.3.2 Traumatic Stress 8
1.3.3 Co-morbidity 10

Chapter 2 - Literature Review 11-27

2.1 Overview 11
2.2 The History and Theoretical Understanding of Pain 11
2.2.1 A Physiological Understanding of Chronic Pain 11
2.2.2 The Gate Control Theory of Pain 12
2.2.3 The Neuromatrix Theory of Pain 13
2.3 Traumatic Stress 14
2.3.1 Trauma the Body and Pain 16
2.3.2 Psychoneuroimmunology 17
2.4 A Review of the Research Related to Chronic Pain and Traumatic Stress 18
2.5 An Integrated Developmental Approach towards Understanding Pain
and Traumatic Stress 22
2.5.1 Somatoform Pain 23
2.5.2 Alexithymia 23
2.6 The Evolution of Psychological Theories of Pain: Integrating Pain and Trauma 24
2.7 Limitations of Previous Research 26
2.8 The Current Study 27

Chapter 3: Methodology 28-37

3.1 Qualitative Research in Psychology 28
3.2 The Design of the Study 29
3.2.1 Ontological and Epistemological Positions 29
3.2.2 Phenomenological Philosophy 30
3.2.3 Hermeneutics 33
3.2.4 Idiography 35
3.3 Interpretative Phenomenological Analysis: Application to Practice 35

Chapter 4: Method 38-54

4.1 Introduction 38
4.2 Ethical Approval 38
4.3 Participant Recruitment 39
4.3.1 Recruitment Process 39
4.4 Introduction to the Participants 43
4.4.1 Sarah 43
4.4.2 Lorraine 44
4.4.3 James 44
4.4.4 Laura 44
4.4.5 Thomas 44
4.5 Procedure 45
4.5.1 Consent 45
4.5.2 Confidentiality 45
Transcription of Interviews 45
Dissemination of Data 46
4.5.3 Data Collection 46
4.6 Data Analysis 47
4.7 Demonstrating Validity and Reliability 51
4.7.1 Sensitivity to Context 51
4.7.2 Commitment and Rigour 53
4.7.3 Transparency and Coherence 54
4.7.4 Impact and Importance 54

Chapter 5: Findings 55-114

5.1 Introduction to Findings 55
5.2 Superordinate Theme 1: “Every day is just such a struggle.” 57
5.2.1 Sub-theme 1: Overwhelmed by chronic pain and traumatic stress 58
5.2.2 Sub-theme 2: Feeling out of control 61
5.2.3 Sub-theme 3: The debilitating impact of living with chronic pain
and traumatic stress 63
5.2.4 Sub-theme 4: Loss of meaning and hope 66
5.2.5 Sub-theme 5: Living with uncertainty: not knowing 68
5.3 Summary 70
5.4 Superordinate Theme 2: Isolation 70
5.4.1 Sub-theme 1: Loss of connection with others 71
5.4.2 Sub-theme 2: Delegitimised and judged by others 73
5.4.3 Sub-theme 3: Invisibility and ambiguity 77
5.5 Summary 78
5.6 Superordinate theme 3: The relationship between chronic pain and
traumatic stress 78
5.6.1 Sub-theme 1: Chronic pain and traumatic stress maintain each
other: “it’s a vicious cycle” 79
5.6.2 Sub-theme 2: “It’s just a battle between the two” 82
5.6.3 Sub-theme 3: Reliving painful memories linked to the pain 83
5.6.4 Sub-theme 4: The body as a container for traumatic stress 85
5.7 Summary 87
5.8 Superordinate theme 4: Chronic pain and traumatic stress change the
relationship with the self 87
5.8.1 Sub-theme 1: “I’m a shell of myself” 88
5.8.2 Sub-theme 2: Reflecting on changes to the self over time 90
5.8.3 Sub-theme 3: Gender identities and roles 94
5.8.4 Sub-theme 4: A lack of self-compassion 97
5.9 Summary 97
5.10 Superordinate theme 5: Ways of coping with chronic pain and traumatic
stress 98
5.10.1 Sub-theme 1 Surviving not coping 98
5.10.2 Sub-theme 4 Feeling guarded: coping with anxiety 100
5.10.3 Sub-theme 2 “I’m here but I’m not here” 101
5.10.4 Sub-theme 3 “I just bottle it up” 102
5.11 Summary 105
5.12 Superordinate theme 6: Moving forward: Learning to adjust/live with
chronic pain and traumatic stress 105
5.12.1 Sub-theme 1: The importance of feeling seen valued as a
person 106
5.12.1 Sub-theme 2: Acceptance 108
5.12.2 Sub-theme 3: Having control over my life 109
5.12.3 Sub-theme 4: Resilience and determination 110
5.12.4 Sub-theme 5: Holding hope 112
5.12.5 Sub-theme 6: Compassion for self and others 113
5.13 Summary 114

Chapter 6: Discussion 115-134
6.1 Overview 115
6.2 Reflecting on the Research Question 115
6.3 Superordinate theme 1: “Every day is just such a struggle” 116
6.4 Superordinate theme 2: Isolation 118
6.5 Superordinate theme 3: The relationship between chronic pain and
traumatic stress 122
6.6 Superordinate theme 4: Chronic pain and traumatic stress changes the
the relationship with the self 126
6.7 Superordinate theme 5: Ways of coping with chronic pain and traumatic stress 127
6.8 Superordinate theme 6: Moving forward: Learning to adjust/live with chronic
pain and traumatic stress 131

Chapter 7: Implications and Recommendations from the Study 135-142

7.1 Contribution to Knowledge 135
7.2 Implications for Policy 136
7.3 Implications for Clinical Practice 138
7.4 Limitations and Suggestions for Future Research 140
7.5 Final Conclusions 141

Chapter 8: Reflexive Statement 143-147
List of Tables
Table no. Page

4.1 Participant Characteristics 43
5.1 Master Table of Superordinate and Sub-themes 56
4.2 The process of data analysis based on guidelines outlined by
Smith et al. (2009) 48
List of Figures
Figure no.
2.1 Factors that contribute to the patterns of activity generated
by the body-self neuromatrix. Adapted from Melzack (2005, p. 91) 14
4.1 Participant Recruitment Process 42

References 148-171

List of Appendices
Appendix 1 172
1.1 Ethical Approval letter Metanoia 173
1.2 Research Ethics Committee letter 174

Appendix 2 176
2.1 Participant Information Sheet 177
2.2 Consent form 180
2.3 Semi-structured interview schedule 182
Appendix 3 186
3.1 Structured Interview for Disorders of Extreme Stress 187
Acknowledgements
I would like to start by thanking the five participants who gave their time to take part
in this study. Without them the study would not have been possible.
Special thanks go to my research supervisor Dr Lucia Swanepoel for her expertise,
guidance, and consistent support from start to finish. I also want to thank Professor
Vanja Orlans and Professor Maria Gilbert who have encouraged me to believe in
myself and my capabilities throughout this journey. I am also extremely grateful to
Dr Helen Molden for her invaluable contributions.
My thanks also go to Dr Lizzie Davey who supported my progress with developing
this area of research leading to ethical approval, participant recruitment and
interviewing.
Further thanks go to Mrs Alison Piper for her support with conducting and writing up
the research within the Department of Clinical Health Psychology, Queen Elizabeth
Hospital. I also want to thank Dr Louise Robinson for her time and constant
encouragement. I am grateful to everyone within the Department of Clinical Health
Psychology and the Pain Clinic for their ongoing support encouragement, patience
and expertise.
Many thanks go to all fellow students and colleagues who have supported and
guided me through formal and informal mentoring. I am grateful to my friends for
their reassurance and patience through the highs and lows.
Finally and most of all I would like to thank my husband David and my children
Robert and Jenny for their continued love, patience and encouragement throughout
the years leading to the completion of this work. When I started this journey I had no
idea what lay ahead. Thank you for believing I would get there in the end. To Mum
and Dad and my sisters Heather and Dawn, thank you for making me the determined
person I am and for the love and encouragement that has kept me going.

Samantha Williams
Abstract

There are few qualitative studies exploring co-morbidity and specifically the
experience of living with chronic pain and traumatic stress. In addition existing
research has focused on the relationship between chronic pain and post-traumatic
stress disorder (PTSD) but has not considered the impact of complex post-traumatic
stress disorder (CTPSD) on co-existing chronic pain.

The aim of this study was to explore the individual’s unique experience of living with
co-morbid chronic pain and traumatic stress. This study also supports a wider
formulation by exploring CPTSD as a construct, acknowledging the diversity of
symptoms beyond the diagnostic criteria of PTSD. Five participants were
interviewed about their experiences. Interpretative phenomenological analysis (IPA)
was used to analyse the data.

An IPA analysis revealed six superordinate themes: 1) “Every day is just such a
struggle”; 2) Isolation; 3) The relationship between chronic pain and traumatic stress;
4) Chronic pain and traumatic stress change the relationship with the self; 5) Ways of
coping with chronic pain and traumatic stress; 6) Moving forward; learning to adjust
and live with chronic pain and traumatic stress.

The super-ordinate themes highlight the everyday reality of living with this co-
morbidity, suggesting that co-morbid chronic pain and traumatic stress do not exist
as separate isolated symptoms but are impacted by individual, relational and social
factors. The results also highlight the complex interrelationship between chronic
pain and traumatic stress.

Implications for policy and clinical practice include raising awareness and providing
access to effective care pathways for clients who live with this distressing co-
occurrence. An integrated treatment approach is required to address the meaning
and multi-dimensional nature of living with this co-morbidity. Recommendations are
made for further research in this area.

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