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Patient Communication of Chronic Pain in the Complementary and Alternative Medicine Therapeutic Relationship

Background: Patient descriptions of pain shape the pain experience, yet there is insufficient understanding of how patient communication can help providers lessen pain’s psychological and physical impact. Objective: To examine how individuals communicate their pain experience in the complementary and alternative medicine (CAM) provider-patient relationship. Method: Qualitative thematic framing examining semistructured interviews of a purposive and snowball sample of CAM patients (N = 13; 850 double-spaced pages) recruited from the mid-Atlantic region of the United States. Results: Complementary and alternative medicine patients communicate the pain experience through an awareness of their interdependence with: (a) relational spaces as attention to the self, the healing practices, and the provider; (b) physical spaces as openness to surroundings and the spatiality and temporality of self; and (c) physiological spaces as breathing and neurological and immune system functioning. Conclusion: A therapeutic relationship cultivating interdependence through awareness of relational, physical, and physiological spaces supports patients’ ability to open up to, know, and accept their body. The CAM provider’s work connects their practice with patient awareness of control over their environment, relationships, and physiology to redefine their pain experience.


Therapeutic Relationship
An estimated 50 million American adults have significant chronic pain (1). Chronic pain has been described as ongoing or recurrent pain that lasts beyond injury or illness for more than 3 to 6 months and adversely affects the individual's well-being (2,3). Patient-provider communication is central to pain management and goes beyond assessing specific components of pain (eg, severity and frequency) to an understanding of the complex array of cognitive, socialenvironmental, and behavioral processes that contribute to patients' pain perception (4,5). Furthering a patient-centered understanding of how individuals communicate their pain experience can help providers lessen pain's psychological and physical impact and increase patient well-being and security (6,7). However, there is insufficient understanding of how the patient's experience of pain is shaped by provider-patient communication through collaborative practices in the therapeutic relationship (eg, shared decision-making) (8)(9)(10). Complementary and alternative medicine (CAM) therapies provide positive pain management alternatives (11,12) situated within a patient-centered therapeutic relationship that supports patient involvement to emphasize subjectivity, embodiment, and preventive care (13,14). Thus, attending to how CAM patients describe their pain can help design patient-centered care in pain management (15). The goal of this study is to examine how CAM patients communicate their pain in the provider-patient relationship.
Complementary and alternative medicine therapies include practices and products of nonmainstream origin such as natural products (eg, botanicals, vitamins, minerals, and probiotics), mind-body practices (eg, acupuncture, meditation, yoga, spinal manipulation), and whole system approaches (eg, Ayurveda, traditional Chinese medicine) (1). Pain management is one of the foremost predictors of the use of CAM therapies by patients (16); however, CAM approaches are often overlooked or underused in patient care protocols (17). For example, guided imagery and acceptance-based mind-body CAM interventions (eg, Thai massage) have been found to facilitate individual involvement, relaxation, and personal control to reduce long-term reliance on medication (18,19). Guided imagery interventions include quiet time, instructions, and visual images to match the patient's preferences for coping style (20). Likewise, mind-body interventions have helped fibromyalgia patients manage symptoms and improve psychological and physical well-being (21), lending support to evidence that directing patients' attention to cognitively demanding tasks can lead to reduction in pain perceptions (22,23).
Existing research suggests how patients communicate pain affects their experience of pain (15), perception of health outcomes (24), satisfaction with health-care providers (6), and nature of care received (25)(26)(27). Patient-centered communication emphasizes compassion and an egalitarian partnership and facilitates inclusion of patient accounts through provider-patient engagement (28), peer-based interaction (5), and a shared philosophy of patient empowerment (7). Such care has been found to be associated with greater patient involvement (29)(30)(31)(32)(33)(34). Communication factors such as listening, openness, and dialogue establish trust and are central to a positive provider-patient relationship (35)(36)(37). These factors contribute toward encouraging patient communication of their illness experience in making clinical assessments, understanding the patient as a person, and engaging in shared decision-making for patient-centered care (7,38). In pain management, a positive patient-provider relationship can influence patient adherence and motivation in adversity to overcome challenges (39)(40)(41). Likewise, challenges to physician-patient relationships are often the consequence of poor physician communication skills, unmet expectations, or competing personality styles that may lead to patient frustration (42).
Complementary and alternative medicine therapies are attractive to patients in part because they offer support to patients whose challenges may include navigating physical, neurological, psychological, social, and spiritual concerns (43). Complementary and alternative medicine provider beliefs support involvement, control, and participation in care (34). While studies on CAM practitioners find an emphasis on the holistic, empowering, and person-centered nature of therapies (44), there is a gap in understanding CAM patients' perspectives in pain management. Understanding how CAM patients describe the pain experience in the therapeutic relationship can provide meaningful insights into how patients can redefine their pain experience and further patient-centered care in pain management.

Methods
This qualitatively grounded pilot study of N ¼ 13 participants actively engaged in pain self-management conducts a thematic frame analysis of patient discourses gathered through in-depth semistructured interviews with the researcher (see Table 1 (45); informed consent was obtained orally and on record). Semistructured interviewing is a data collection strategy in which the question protocol is predetermined but open ended to allow the researcher more control over the topic of the interview but allow for exploration of ideas and topics from the participant discourse (45). The interviews were audio-recorded and transcribed verbatim by a professional transcriptionist agency (data set available upon request from author[s]). The institutional review board of Salisbury University granted approval for the study.
As part of the larger data set, the researcher observed CAM provider-patient sessions and spaces for objects, artifacts, and journaled observations (not reported). Qualitative research helps understand the experience of illness and makes sense of the complex processes to shape peoples' experience of health care and thus to improve it. By using the concept of framing, which involves the selection of "some aspects of a perceived reality [to] make them more salient," the researcher can arrive at a more directed understanding of the problem (46, p52) situated in the context of individual assumptions, experiences, and perceptions (47). Analyzing the frames employed by chronic pain patients provides an understanding of the communicative context within which alternative care is perceived as effective. As pain management is a subjective domain, understanding how patients understand the encounter and what its salient themes are for chronic pain management in alternative care can contribute to health communication praxis in the therapeutic relationship.
In synthesizing the interviews, the patient voices in the interview texts were examined by the author with a focus on how they engaged the therapeutic relationship and positioned the individual in the discourse. The final themes were reviewed and refined where necessary with a nursing colleague with experience in holistic nursing and over 25 years of public and community health experience in the author's academic institution to strengthen validity. For the review of the final themes, the author and the nursing colleague read through and collectively discussed the themes to clarify questions and achieve agreement on theme categorization and interpretation. This process resulted in refining the second theme (eg, "awareness of physical spaces" was refined to emphasize the experiential quality of physical spaces). Following the qualitative interpretive research tradition, the analysis of participant transcripts has been presented in detail to explicate their communicative themes. Data analysis was based on open coding and axial coding techniques (48) of the participant interview transcriptions (49). This study reports findings from part of the complete data set.

Results
The analysis revealed individuals with chronic pain communicate their pain experience in the CAM provider-patient relationship through an awareness of their interdependence with (a) relational spaces, (b) physical spaces, and (c) physiological spaces ( Table 2).

Awareness of Relational Spaces
Complementary and alternative medicine patients' communication of pain revealed an awareness of interdependence in the self with its body movements, the practices of their CAM therapy, and their provider. In relating, patients were able to open up to others, the environment, the practice, and the provider. For example, Tim described being aware of his body movements as they related to the environment: "monitoring [the] body as [it] moves through down the road"; the CAM therapy, described as "organic-help my soul stay open" (John); or the CAM provider, who "listened to me and . . . focused on where I told her I needed extra attention" (Brie).
In their healing process, participants saw the therapy in relationship with other practices, describing CAM therapy as the flow of "many rivers leading to the same source" (Tim).
Likewise, participants became aware of their connectedness: "every human has the same ability to be healed. So instead of focusing on our differences we should focus on our similarities" (Kate). Participants became aware of the relationship of their provider's actions as they shaped their outcomes, such as how the practitioner "does things . . . pushing and pressing, and pulling and stretching and twisting . . . that seemed to change the muscles, in the legs, in the back, in the arms and the neck" (Mark). Finally, participants became aware of their own relationship with the healing process: "I don't think it's changing the deterioration, but it's changing the way my body is responding to the deterioration, and reducing the pain" or, as Mark elaborated, gaining an "awareness of the relationship between ungraceful body movements and pain" (Mark).
Brie's awareness of how her relationship with her practitioner "improved my lifestyle," in turn, made her feel "comfortable with her," and "trust her." For Brie: "that's what's allowed me to open up to it even more," by implicitly giving permission to her practitioner "to treat me unconditionally." Alex noted being aware of his spatiotemporal relationality, seeing himself as: "a long-term version of just many snapshots of present time, getting better over time, or, not getting worse." He became aware of how: "before I The examples in this theme illustrate participant awareness of their relational spaces of the self with the body, healing practices, and the provider. Participant awareness of interdependence in these relational spaces shaped their pain experience through directing attention to their relationship with their body movements, with others, the environment, provider, and the treatment therapy, and in redefining their pain outcomes in becoming self-monitoring, open, aware of their ability to heal, and knowing the body.

Awareness of Physical Spaces
Complementary and alternative medicine patients' communication of pain revealed an awareness of how physical spaces constitute their lived environments through their senses and how, in turn, their response to the physical spaces shaped their sensory experience of pain. Kate, a cancer survivor, said: "I do kayaking . . . you have to be grounded, so you spend earth time . . . feet in grass, sand, feet in the sand, swimming in the ocean, walking in the woods." John tries to "block everything else out, cleanse the room out," to have "a dark setting, nice music, essential oils, [and] heating mats for tables" for his therapeutic experience. He emphasizes physical spaces, the: "room is not so sterile looking; [it's] visual, sensory, relaxes you as soon as you walk into the room" (John).
Mark described the physical space of his practice: "we're in a quiet room . . . she's attentive to smell. So the lotion(s) . . . are designed to have smells that are positive." For Mark, "the atmosphere helps. The more . . . I can respond to the quiet, and the good smells, and the music . . . the more effective the techniques are." Gabe described the "quietness, relaxing, not be in pain, music, soft lighting, crystals." Kim's description ("my chiropractor has advised me about things like the shoes that I wear, the size of purse that I carry . . . the pillow") illustrates how she became aware of the objects in her life alongside her awareness of: "the things you can do to modify that" such that: "now, [I'm] aware that those nerves had the pressure taken off of them, then the headaches were able to get better . . . I'm able to understand . . . what my doctors have been telling me." Kim noted this made her "more aware of the effect your choices have." The theme of awareness of physical spaces captures participants' experience of their surroundings, ranging from the sensation of walking on the earth, the feel of music, to smells in a room. Participants' interdependence with physical spaces shaped their pain experience through enhancing awareness of their control over lifestyle choices such as walking, room layout, and belongings (eg, shoes, purses, pillows) and helped them redefine their pain outcomes as feeling grounded, relaxed, cleansed, and responsive to sensations (eg, smells, music).

Awareness of Physiological Spaces
Complementary and alternative medicine patients' communication of pain revealed an awareness of their interdependence with physiological spaces in coproducing the pain experience. Physiological spaces, understood as the body's organs and parts as they relate to its functioning, were illustrated in participant descriptions through connecting awareness of their pain alongside actions such as breathing. Mark mentioned how his practitioner will: "remind me to breathe in deeply or breath out . . . in relationship to the movement she's making [and] then I can experience . . . [a] noticeable change in the . . . pain in mind." Alex's description illustrates an awareness of his functionality despite: "severe neurological pain. I'm always in pain. There's never a moment that I The patient's awareness of the connectedness of the self with the relational, physical, and physiological spaces in defining the experience of pain Awareness of relational spaces Awareness of interdependence of self and movement through time Awareness of interdependence of self and practices of healing Awareness of interdependence of self and provider Becoming self-monitoring, connected with self and others, aware of own healing ability, and knowing the body Awareness of physical spaces Awareness of interdependence of self and sensations Awareness of interdependence of self and its spatiotemporality Awareness of interdependence of self and belongings Feeling grounded, cleansed, relaxed, responsive to sensations, openness

Awareness of physiological spaces
Awareness of interdependence of self and physical functions of body Awareness of interdependence of self and neurological and immune functions of body Awareness of interdependence of self and body's energy Awareness of interdependence of self and sensing Feeling focused, a sense of clarity, and able to "hear body" can even remember that I wasn't in pain . . . but I'm still able to function." Sue's description illustrated an awareness of others, "whether somebody's energy is heavy or whether it's light and airy." Her practitioner "helped me understand that my immune system doesn't attack the pathogens. And so if it's really suppressed, then . . . I'll get symptomatic." These examples illustrate how participants connected awareness of physiological spaces with body functions and the pain experience. Kate's description illustrates her experience of physiological spaces as: "cleaning out your body from all the toxicity," such that, "all of a sudden you can hear your body again." Likewise, Pam noted her therapy was: "meaningful in terms of how my body feels and the results I get from the practices . . . the mind-body marriage of the practices." Pam and Kate's comments illustrate awareness of the body in terms of feelings, the practice, and the mind-body connection. John described how his practice with his provider helps him: "clear my mind [and help] focus." Mel became aware of the sense of touch, noting she: "like(d) to be touched . . . I have this clarity and energy and happiness that I didn't have. That to me is the biggest thing." Participant examples in this theme illustrate an awareness of physiological spaces as breathing, neurological and immune system functioning, and sensing. Participants' interdependence with physiological spaces shaped their pain experience through enhancing awareness of their perceptions and understanding of body functions and symptoms and through helping them redefine pain outcomes as cleansing, focusing, and providing clarity.

Discussion
The study furthers understandings of how patients' experiences of pain are shaped by an awareness of their interdependence with relational, physical, and physiological spaces and how this interdependence helps patients redefine their pain outcomes. The pain experience can be isolating and fearful, often leaving patients with a sense of loss of control and consequently an increased sense of body dissociation (50). The findings make an important contribution by foregrounding the role of interdependence in helping patients feel in control and thereby redefine their pain experience and outcomes. Through interdependence, patients come to see themselves in integrative ways in their social, physical, and environmental relations, to open up to experiencing themselves through their physical spaces and its spatiotemporality, and to gain confidence in their knowledge of their own physiology through breathing, organ and system functionality, and the senses. Awareness of their interdependence helped enhance patients' perceived ability to identify and connect with shared commonalities, healing abilities, and to recognize their own body's healing process. In doing so, patients moved beyond the immediate experience of pain to an awareness of how it was not simply the deteriorating body but their response to the deteriorating body defines the pain experience.
A provider-patient relationship that cultivates interdependence through awareness of relational, physical, and physiological spaces in patients supports patients' ability to open up to, know, and accept their body by becoming less fearful of the body in pain ( Table 2). The CAM provider's work of carefully connecting their practice with the awareness in the patient of their control over their environment, their relationships, and their physiology helped patients in the process of fundamentally redefining the pain experience and outcomes. Patients described their journey from seeing themselves as controlled by, and in turn, rejecting, a body in pain, to describing themselves as self-monitoring, with knowledge of their body, and able to make choices about their environment and lifestyle. Patient experience of interdependence illustrated their ability to feel healed by redefining pain outcomes as feeling grounded, relaxed, cleansed, focused, and open to a range of sensations from the physical body. The study findings suggest that provider communication facilitating an awareness of interdependence is central to feeling connected, open, and accepting and can help patients integrate with their whole sense of self.
By connecting the patient's perception of pain with its somatic and experiential mechanisms, the findings suggest that the conceptual mechanisms of interdependence integrate the patient's ability to manage chronic pain through gaining control and knowledge of their body, of confidence to open up to the body's sensations, and of trust in their ability to move from limiting neuropsychophysiological pain perceptions to whole-body experiences of clarity and focus. The perception of chronic pain engages brain regions critical for cognitive and emotional assessments (23). Chronic pain affects the patient, their family, and the patient's social and work relationships. Provider-patient communication connecting the patient's awareness of balance and interdependence in multidimensional relational, physical, and physiological contexts supports patient cognizance of pain through active adjustment, acceptance, and engagement.

Limitations
Complementary and alternative medicine patients selfreported their experience of pain in the CAM relationship and received pain management support through alternative therapies. The study did not distinguish between diagnosis of nociceptive and neuropathic pain and did not recruit patients based on a clinical diagnosis. As a descriptive study, the indepth analyses conducted by the author of a small purposive sample provide rich, explorative data for further examination by larger studies. The data analysis was conducted in its entirety by the author with the final themes reviewed in collaboration with a nursing colleague, thus intercoder reliability was not calculated.

Conclusion
Chronic pain challenges patients to manage despite limitations on their ability to participate fully in their daily life, to live productively with pain, feel understood, and navigate pain's effects on their physical and mental well-being (3). The study recommends cultivating interdependence through the provider-patient relationship to help patients gain control, open up to, and reintegrate with others, their spatiotemporal environments, and their whole body, thus allowing them to reframe their experience of pain. Few studies have explicitly focused on patient descriptions in the management of chronic pain through the therapeutic relationship. The themes contribute to patient-centered care by highlighting how provider communication in the therapeutic relationship can guide patients toward awareness of interdependence with their relational, physical, and physiological spaces and empower them to redefine the pain experience.

Author's Note
An earlier version of the article was presented at the 2018 International Congress for Integrative Medicine & Health, Baltimore, Maryland.

Acknowledgment
The author would like to acknowledge Tina B. Reid, EdD, RN, Associate Professor of Nursing, Department of Nursing, Salisbury University, Maryland, for her feedback on the final themes of the findings section for validity. The author is grateful to the complementary and alternative medicine providers for their support in participant recruitment.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded in part by the Fulton School of Liberal Arts, Salisbury University, Salisbury, Maryland.