Background & Aims

Mindfulness-based interventions (MBIs) are increasingly used to treat chronic pain, with some MBIs, such as, Mindfulness-Oriented Recovery Enhancement (MORE), specifically designed to target it. A key component of MORE is its process of guided inquiry: PURER. MORE sessions involve a rich dialogue between the instructor and participants about mindfulness experiences and participants’ relationship to pain. However, the dialogue occurring within MORE, and MBIs generally, have rarely been examined qualitatively to understand how participants learn and apply mindfulness skills for pain management. This qualitative study analyzed 30 session recordings from a randomized controlled trial of MORE (n=71) for patients with lumbosacral radiculopathy (LR) to identify themes in participant experiences with mindfulness, pain perception, psychosocial sequelae of pain, and how these evolved over the 8-week MORE intervention.We conducted verbatim transcription and qualitative coding of recordings from a randomized controlled trial of MORE for patients with LR.1,2 Qualitative coders were blinded to the mindfulness session number such that they did not know where within the 8-week program that session occurred. We used an iterative process of codebook development and subsequent thematic analysis to develop themes related to the impact of MORE on the experience of pain and its psychosocial sequelae.3 Some definitions in our codebook were informed by pre-existing characterizations of meditation experiences, meta-analytic investigations of psychological pain sequelae, and the MORE manual.4,5,6 Qualitative coding focused on the process of guided inquiry into participant pain experiences to explore 1) how participants used mindfulness to manage their pain and 2) how participants’ understanding of mindfulness changed throughout the program.

Methods

We conducted verbatim transcription and qualitative coding of recordings from a randomized controlled trial of MORE for patients with LR.1,2 Qualitative coders were blinded to the mindfulness session number such that they did not know where within the 8-week program that session occurred. We used an iterative process of codebook development and subsequent thematic analysis to develop themes related to the impact of MORE on the experience of pain and its psychosocial sequelae.3 Some definitions in our codebook were informed by pre-existing characterizations of meditation experiences, meta-analytic investigations of psychological pain sequelae, and the MORE manual.4,5,6 Qualitative coding focused on the process of guided inquiry into participant pain experiences to explore 1) how participants used mindfulness to manage their pain and 2) how participants’ understanding of mindfulness changed throughout the program.

Results

The MORE group of the RCT (n=37) was primarily white (70%) and female (81%) with an average age of 48.59.1 We have coded ~70% of the recordings and three core themes characterized participants’ learning of mindfulness and application for pain management: 1) MORE’s structured model of inquiry: PURER (Phenomenology, Utilization, Reframing, Education, Reinforcement), 2) pain relief and the shift of pain perceptions, and 3) disabling factors in the experience of chronic pain. The inquiry process encompassed dialogue in which the MORE instructor used questions to help the participant reveal novel insights about their pain experience. This led to descriptions of metacognitive awareness: “noticing the way that I’m noticing pain… I feel like my relationship to it is changing”, successful experiences with pain reappraisal: “The pain went from feeling hot to… a cooling sensation”, and experiential avoidance of pain: “I’ve actually practiced a little bit… it becomes like a superpower… to fly somewhere else away from your sorrows and away from the pain that you’re steeping in”. Unique to this qualitative methodology, the descriptions of mindfulness and pain experiences came directly from the MORE sessions themselves.

Conclusions

Using a well operationalized model of instructor-guided inquiry, MORE helps participants change their relationship to their pain and manage their pain experience. Qualitative analysis of dialogue from MORE sessions demonstrates the potential to evaluate MORE, and potentially other MBIs, as they are experienced by the participants throughout each session as opposed to asking participants about their experience via study exit interviews. Using this approach, we found that MORE session recordings contain rich qualitative data that may hold useful insights about how participants learn core mindfulness skills to help manage symptoms of pain and we were able to build upon the conceptual model of MORE’s therapeutic effects. In addition, we found that some participants may use mindfulness practices as a form of experiential avoidance rather than reframing of pain perceptions. Future clinical trials of MBIs should plan to include sessions recordings as part of mixed methods study designs.

Using a well operationalized model of instructor-guided inquiry, MORE helps participants change their relationship to their pain and manage their pain experience. Qualitative analysis of dialogue from MORE sessions demonstrates the potential to evaluate MORE, and potentially other MBIs, as they are experienced by the participants throughout each session as opposed to asking participants about their experience via study exit interviews. Using this approach, we found that MORE session recordings contain rich qualitative data that may hold useful insights about how participants learn core mindfulness skills to help manage symptoms of pain and we were able to build upon the conceptual model of MORE’s therapeutic effects. In addition, we found that some participants may use mindfulness practices as a form of experiential avoidance rather than reframing of pain perceptions. Future clinical trials of MBIs should plan to include sessions recordings as part of mixed methods study designs.

References

  1. Wexler RS, Fox DJ, ZuZero D, et al. Virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) reduces daily pain intensity in patients with lumbosacral radiculopathy: a randomized controlled trial. Pain Rep. 2024;9(2):e1132. doi:10.1097/PR9.0000000000001132
  2. Wexler RS. Protocol for mindfulness-oriented recovery enhancement (MORE) in the management of lumbosacral radiculopathy/radiculitis symptoms: A randomized controlled trial. Contemporary Clinical Trials Communications. Published online 2022.
  3. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  4. Lindahl JR, Fisher NE, Cooper DJ, Rosen RK, Britton WB. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS One. 2017;12(5):e0176239. doi:10.1371/journal.pone.0176239
  5. Garland EL. Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain. NASW Press, National Association of Social Workers; 2013.
  6. Rogers AH, Farris SG. A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. Eur J Pain. 2022;26(8):1611-1635. doi:10.1002/ejp.1994

 

This study was approved by the National University of Natural Medicine (NUNM) IRB (IRB#: KP112720). Data were collected following the previously described protocol by Wexler et al.

Presenting Author

Ryan Wexler

Poster Authors

Ryan Wexler

ND, MSCR

National University of Natural Medicine

Lead Author

E-mail

Wade T. Balsamo

Himalayan Institute

Lead Author

E-mail

Danielle ZuZero

BS

National University of Natural Medicine

Lead Author

E-mail

Lydia Norby-Adams

BA

National University of Natural Medicine

Lead Author

E-mail

Anna Osman

BS

National University of Natural Medicine

Lead Author

E-mail

Anand Parikshak

Lead Author

Ryan D. Bradley

ND

National University of Natural Medicine

Lead Author

E-mail

Courtney K. Pickworth

ND

Lead Author

E-mail

Topics

  • Mechanisms: Psychosocial and Biopsychosocial

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