부산대학교 도서관

Chronic pain is a long-term condition affecting an estimated 28 million people in the UK. Progress has been made in understanding, developing and supporting self-management for those with chronic pain. However, an unknown number of people have been excluded from or been unable to access the kind of multidisciplinary pain management services that are thought to be of benefit for supporting self-management. Little is known about their experiences and what they do that constitutes self-management. Applying an interdisciplinary logic spanning several research traditions, this thesis examines how self-management of chronic pain is understood and enacted. I ask, "How is 'self-management' achieved by people living with chronic pain who have been excluded from or have dropped out of existing pain management services, and how can they be better supported in policy and practice?" I start by situating myself as a curious clinician seeking to understand the experiences of my patients as well as the system in which I offer care, before presenting a hermeneutic literature review of self-management of chronic pain to understand the academic context in which this topic is situated, attending to the epistemological positions that have contributed to what is known about self-management of chronic pain. I conducted, then set out findings from an intrinsic case study of self-management of chronic pain combining data from seven qualitative cases of patients living with chronic pain who have been excluded from or dropped out of pain management services, with 16 interviews with health care professionals and managers, seven interviews with policy actors and analysis of relevant policy documents. My analysis shows how self-management of chronic pain is not singularly understood or practiced by participants in my study. Drawing on (and extending) the work of Annemarie Mol and Scott Graham, I present multiple ontologies of pain that influence which services are set up and how, and how they're delivered and offered (or not) to patients. I show how those living with pain in my study sometimes bypassed formal services - that typically privilege empirical and biomedical approaches to pain and pain management - in favour of more workable ontologically aligned care. They continually re(form) relational, socio-material entanglements with people, places and objects that offer support for living with pain. This is in stark contrast to the contemporary discourse and practice of 'self-management' in chronic pain, which I argue is a fallacy stemming from neoliberal health policy. I conclude by arguing that the presence of contrasting pain ontologies has resulted in practitioners experiencing ontological conflict when trying to deliver modernised, technocratic services for chronic pain, and patients and practitioners experiencing uncertainty and distress when negotiating the health care system. I propose a different way of thinking about access to specialist pain services, inviting decision makers and practitioners to extend support for chronic pain to non-health care settings, and to attend more closely to the socio-material entanglements and relational aspects of living with chronic pain.