Consciousness, complexity and chronic pain : exploring the occurrence and implications of incongruent beliefs about 'important' chronic pain treatment components
Background: The biological sciences have contributed an extensive volume of research in efforts to
resolve the issue of chronic pain. An expanding body of research, focusing on the psycho-social
aspects of chronic pain, is also now evident. Paradigms applied to chronic pain appear to compete and
lack an integrative framework.
Aims: The original aim of this study was to identify and explore patterns of congruence that exist
between service users and providers in relation to beliefs about which treatments for chronic pain are
important. At the outset this research took a constructivist position, based within existing research
which demonstrates that beliefs about chronic pain and its treatment are individually constructed and
that lack of agreement between people with pain and treatment providers may contribute to negative
treatment outcomes. As the iterative process of the research unfolded the aims of determining if a
complex adaptive systems (CAS) analysis was appropriate for chronic pain and whether
recommendations for change could legitimately be generated using a CAS paradigm, emerged.
Methods: The literature was reviewed to identify conceptualizations of, and interventions for,
chronic pain. Based on this information the Stage one postal survey, gathering service users' and
providers' opinions about important treatment components, was designed. The survey also included
Skevington's standardised Beliefs About Pain Control Questionnaire (BPCQ). The second stage
employed Delphi methodology. A series of iterative questionnaires explored the original questions
about congruence of beliefs, perceived impact of disagreement and suggestions for action. As
additional information emerging from each Delphi round the analysis employed firstly a constructivist
framework and ultimately explored the usefulness ofreframing chronic pain within a CAS
Findings: The participants in this study had very little inter and intra-group congruence of beliefs.
While service users believed that their decision-making was influenced by four domains of the
Chapman's Consciousness model (coherence, purposiveness, affect and self-image) as derived from
constructivist theory, service providers stated that affect and self-image were not strong influences.
Participants agreed that some action should be taken when there is disagreement about important
treatments and the overwhelming majority of recommendations focused on actions the service
providers should take. Very few recommendations were made of actions for the service users.
Participants' responses in Delphi 3 indicated that chronic pain had a number of elements consistent
with a CAS but that more linear and conflicting beliefs were also strong.
Discussion and Conclusions: A constructivist perspective in itself proved insufficient to explore
chronic pain's resistance to change and the implications of this for intervention. By applying CAS
theory to the three key features that emerged from Delphi 1 and 2 (incongruent beliefs, differential
access to information and paradoxical beliefs and behaviours) the phenomenon of chronicity was
reframed. Interventions, based on complexity science principles, can effect change in the highly
interactive systems that constitute the chronic pain experience. A complexity science paradigm can
serve as a meta-framework, integrating the currently competing theoretical models employed in
chronic pain. The NHS Modernisation Agency, and other researchers and theorists, have provided
complexity science based policy statements and recommendations for affecting change in a range of
healthcare settings. These can be examined for patterns and examples of how dissent and conflict can
be a positive generative force for change. Examples and patterns in turn, can form templates to guide
reframing the practice and operating paradigm for chronic pain service delivery.