"I am allowed to be myself": women with chronic muscular pain being recognized

A breathing space: how young Norwegian women engaging psychomotor physiotherapy to address long-term health disorders narrate their experiences

INTRODUCTION

In Norway, as elsewhere, young people may experience psychological distress and long-lasting pain. Such health disorders can be complex, leading some young people to seek psychomotor physiotherapy treatment. Thus far, however, there has been little qualitative investigation of their experiences.

OBJECTIVE

The purpose of this study was to gain new knowledge about the illness experiences of young people with long-term health disorders engaging psychomotor physiotherapy.

METHOD

Qualitative interviews with ten Norwegian women aged 16-24 in psychomotor physiotherapy were analyzed within a narrative framework.

FINDINGS

The participants' treatment experiences take place in the context of a long history of pain, distress, and lack of understanding and support. Their stories tell of being threatened by illness and other difficult life events, and of being placed under further stress by a prolonged and disruptive quest for help within the healthcare system. For participants, psychomotor physiotherapy represents a breathing space where their illness experiences are acknowledged, enabling them to find rest and explore their bodily reactions and habits.

CONCLUSION

Long-term health disorders represent significant disruptions to the daily lives and relationships of young women. It is important to acknowledge the illness experiences of these young women and establish trustful therapeutic relationships. Psychomotor physiotherapy may offer significant potential as a means to help young people explore and make sense of their illness experiences.

Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners

BACKGROUND

When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides.

OBJECTIVES

To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful.

METHODS

Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation.

RESULTS

Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function.

CONCLUSIONS

Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.

Multiprofessional assessment of patients with chronic pain in primary healthcare

Background and aims Chronic pain is a common reason to seek health care. Multimodal rehabilitation is frequently used to rehabilitate patients with complex pain conditions. The multiprofessional assessment that patients go through before entering multimodal rehabilitation may, in itself, have a positive impact on patient outcome but little is known regarding patients own view. Therefore, the purpose of this study was to discover how patients experienced this multiprofessional assessment project. Methods Ten patients participating in a multiprofessional assessment at a primary healthcare centre in Western Finland were interviewed using a semi-structured interview. Qualitative content analysis was used to analyse the interviews. Results The analysis resulted in six categories of participant description of their multiprofessional assessment experiences and the rehabilitation plan they received. Feeling chosen or not quite fitting in was a category describing participant feelings upon starting the assessment. They expressed their thoughts on the examinations in the category more than just an examination. Being affirmed described participant desire to be taken seriously and treated well. Receiving support described the perceived roles of the team members. Participant negative experiences of the assessment were described in confusion and disappointment. Finally, in taking and receiving responsibilities, participants described their own role in the team. Conclusions Experiences of patients in a multiprofessional assessment were mostly positive. This highlights the value of a team assessment that takes several aspects of chronic pain into account when assessing complex patients.

Anxiety management: Participants' experiences of a physiotherapeutic group treatment in Swedish psychiatric outpatient care

Anxiety disorders are among the most persistent mental health syndromes. There is extensive research showing effectiveness of pharmacotherapy and psychotherapy interventions targeting anxiety, while knowledge is still sparse for other treatment options. The aim of this study was to explore how participants with anxiety disorders experience a physiotherapeutic group treatment in psychiatric outpatient care, and their perceived ability to manage anxiety within two months after participating in the treatment. Semi-structured interviews with participants were conducted to explore experiences of the treatment. Data were analyzed using qualitative content analysis, which resulted in one main theme: Reconnecting to the body in the supportive atmosphere of a group. Six categories reflect the main theme: (1) sharing with others supported by the group, (2) grounding oneself in the body, (3) getting to know the body and learning to manage its reactions, (4) learning to tolerate bodily sensations of anxiety, (5) gaining a more compassionate attitude toward oneself, and (6) challenging old patterns to become more active in life. The participants reported that their ability to reconnect to their bodies increased so that anxious sensations became more endurable and acceptable after treatment. The supportive group context was described as valuable, enabling the participants to feel safe enough to start exploring new ways to manage anxiety. In conclusion, this study suggests that a physiotherapeutic group treatment can be a useful add-on treatment to the standard treatment models of anxiety disorders, including psychotherapy and pharmacotherapy, since it targets the embodied, nonverbal domain of anxiety.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain.

PURPOSE

The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention.

DATA SOURCES

Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016.

STUDY SELECTION

Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention.

DATA EXTRACTION

A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence.

DATA SYNTHESIS

Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends.

LIMITATIONS

This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located.

CONCLUSIONS

The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

Living with a disability: a qualitative study of associations between social relations, social participation and quality of life

PURPOSE

We explored which shared aspects of social relations were considered important to the quality of life of persons between the ages of 10 and 40 years living with a disability. We examined how social relations were experienced as affecting quality of life and social participation.

MATERIALS AND METHODS

Fifteen focus groups involving 48 persons with disabilities were conducted using photo elicitation, preference ranking and props. Focus group interviews were supplemented with seven individual interviews with individuals unable to participate in focus groups. All focus group interviews and individual interviews were audiotaped, transcribed, and thematic data analysis was conducted.

RESULTS

We identified caregiving, dependency, and understanding as essential for quality of life. Acceptance from society, discrimination and prejudice, and the ability to participate in society were also highlighted as affecting quality of life. The use of social tactics to avoid confrontation with certain aspects of their disability was common among participants.

CONCLUSIONS

Across disabilities, caregiving, dependency, understanding and acceptance, and discrimination and prejudice were all important aspects for the quality of life of the individuals. Social relations were closely related to social participation, and the latter affected the quality of life of the participants. Social tactics were used to navigate social relations. Implications for rehabilitation We suggest to formalize the concept of social tactics and use it in patient education to enhance quality of life in individuals living with disabilities. People may accept and learn to cope with the impact of their disability, but how they maintain their social participation and social relations also impact on their quality of life. In their assessment, professionals working with individuals with disabilities should, therefore, give more priority to analyze the impact of social relations. When intervening, an effort to establish and maintain social relations should be considered along with psychological help, allocation of aids and economical support aiming to enhance quality of life and social participation among individuals with disabilities. When evaluating efforts to improve quality of life, it is important to investigate whether the intervention has improved the social relations.

How can group-based multidisciplinary rehabilitation for patients with fibromyalgia influence patients' self-efficacy and ability to cope with their illness: a grounded theory approach

AIMS AND OBJECTIVES

To describe how group-based multidisciplinary rehabilitation for patients with fibromyalgia can influence patients' self-efficacy and ability to cope with their illness.

BACKGROUND

Multidisciplinary rehabilitation is recommended in the management of fibromyalgia. Self-efficacy is said to influence and predict adaptive coping behaviours and functioning. However, knowledge is lacking on how rehabilitation programmes may influence self-efficacy and ability to cope, from the patients' perspective.

DESIGN

Grounded theory study of semi-structured focus group interviews.

METHODS

Participants (n = 17) were included in four focus groups that had completed a two-week multidisciplinary rehabilitation programme together. Interviews were conducted four weeks after each group had completed the programme. The analysis was conducted constant comparatively applying open, axial and selective coding.

RESULTS

Categories (in italics) were derived from data in which the explanatory core category was identified: Learning to accept and live with pain as a life condition, and linked to three categories mutually influencing each other: Increased self-acceptance of living with the illness, experiencing acceptance from others and developing new coping strategies. Thus, patients benefitted from multidisciplinary rehabilitation with stronger self-efficacy and expectations to their future coping. However, limitations in the programme were identified, as the programme was short and intensive with no subsequent follow-up, and social welfare was not sufficiently addressed. Participants also found it difficult to maintain knowledge and were lacking individual sessions with the psychologist and had waited long to receive rehabilitation.

CONCLUSION

Multidisciplinary rehabilitation may advantageously be offered to patients with fibromyalgia. However, earlier action with longer programmes, in which patients' social situation is addressed, comprising individual sessions with the psychologist, with multiple repetitions of the content and follow-up sessions, may further enhance the patients' self-efficacy and coping with their illness.

Theory and interpretation in qualitative studies from general practice: Why and how?

Objective: In this article, I want to promote theoretical awareness and commitment among qualitative researchers in general practice and suggest adequate and feasible theoretical approaches. Approach: I discuss different theoretical aspects of qualitative research and present the basic foundations of the interpretative paradigm. Associations between paradigms, philosophies, methodologies and methods are examined and different strategies for theoretical commitment presented. Finally, I discuss the impact of theory for interpretation and the development of general practice knowledge. Main points: A scientific theory is a consistent and soundly based set of assumptions about a specific aspect of the world, predicting or explaining a phenomenon. Qualitative research is situated in an interpretative paradigm where notions about particular human experiences in context are recognized from different subject positions. Basic theoretical features from the philosophy of science explain why and how this is different from positivism. Reflexivity, including theoretical awareness and consistency, demonstrates interpretative assumptions, accounting for situated knowledge. Different types of theoretical commitment in qualitative analysis are presented, emphasizing substantive theories to sharpen the interpretative focus. Such approaches are clearly within reach for a general practice researcher contributing to clinical practice by doing more than summarizing what the participants talked about, without trying to become a philosopher. Conclusions: Qualitative studies from general practice deserve stronger theoretical awareness and commitment than what is currently established. Persistent attention to and respect for the distinctive domain of knowledge and practice where the research deliveries are targeted is necessary to choose adequate theoretical endeavours.

Insights into Pain: A Review of Qualitative Research

Qualitative research exposes and explores important aspects of the pain experience that are inaccessible to other approaches.Qualitative work adopts a different epistemological and ontological perspective to quantitative work.Qualitative research is not well established in the field of pain, but is growing.More interpretative engagement with qualitative data is required.

To be held and to hold one's own: narratives of embodied transformation in the treatment of long lasting musculoskeletal problems

This study elaborates on narrative resources emerging in the treatment of longlasting musculoskeletal and psychosomatic disorders in Norwegian psychomotor physiotherapy (NPMP). Patients' experiences produced in focus group interviews were analyzed from a narrative perspective, combining common themes across groups with in depth analysis of selected particular stories. NPMP theory expanded by Løgstrup's and Ricoeur's philosophy, and Mattingly's and Frank's narrative approach provided the theoretical perspective. Patients had discovered meaning imbued in muscular tension. Control shifted from inhibiting discipline and cognitive strategies, towards more contingence with gravity and sensation, and increased freedom to be what and who they were. Trust, time, open speech, and being respectfully listened to were described as therapeutic pre-conditions. The body was experienced as the source of their voice as their own. As tension patterns transformed, novel experience in sensation appeared to feed narrative imagination, reshaping past plots, embodied identity and future prospects. NPMP was disclosed as a treatment integrating detection, battle and repair as narrative subplots, but the core narrative was the journey of transformation. Novel embodied narrative resources nourished the quest for a life and identity in tune with the body as one's own.

Time to gain trust and change--experiences of attachment and mindfulness-based cognitive therapy among patients with chronic pain and psychiatric co-morbidity

The treatment of patients with chronic pain disorders is complex. In the rehabilitation of these patients, coping with chronic pain is seen as important. The aim of this study was to explore the meaning of attachment and mindfulness-based cognitive therapy (CT) among patients with chronic pain and psychiatric co-morbidity. A phenomenological approach within a lifeworld perspective was used. In total, 10 patients were interviewed after completion of 7- to 13-month therapy. The findings reveal that the therapy and the process of interaction with the therapist were meaningful for the patients’ well-being and for a better management of pain. During the therapy, the patients were able to initiate a movement of change. Thus, CT with focus on attachment and mindfulness seems to be of value for these patients. The therapy used in this study was adjusted to the patients’ special needs, and a trained psychotherapist with a special knowledge of patients with chronic pain might be required.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Shelter from the storm; men with chronic pain and narratives from the rehabilitation clinic

OBJECTIVE

To examine the meaning of participating at a rehabilitation clinic in the lives of men with chronic pain.

METHODS

The material consists of qualitative interviews with 10 Norwegian men with chronic neck pain, and was analyzed using narrative method, combined with a gender sensitive perspective.

RESULTS

With references to 'identification of a cause' and 'rebuilding physical strength', the significance of medical expertise initially seemed to be linked to restoring bodily function. In the men's individual lives, however, the meaning of being in rehabilitation extended far beyond achieving manifest treatment goals and was also linked to profound human needs, such as to (re)build a self, to be comforted and connected to others.

CONCLUSION

As rehabilitation clinics may provide a legitimate space in which men's experiences of pain are 'housed', they may constitute significant sources for restitution work, as well as significant shelters against social accusation that they are not really sick.

PRACTICE IMPLICATIONS

We suggest that health professionals should be aware of the social significance rehabilitation clinics may represent for men living with chronic pain.

Myopathy following postoperative ablative radioiodine for follicular carcinoma of the thyroid

We highlight a case of disabling myopathy following radioablative iodine treatment for follicular carcinoma of the thyroid. A 34-year-old man presented with a tender neck swelling, ultrasound and biopsy were suggestive of thyroid malignancy. Thyroidectomy was undertaken and histology confirmed follicular carcinoma of the thyroid. Treatment with ablative radioiodine followed and within days the patient developed disabling myopathy. Investigations to date do not reveal any other cause for the myopathy and there is no evidence to suggest that this is a paraneoplastic phenomenon. We believe this is the first reported case of ablative radioiodine-induced mypoathy.

Diagnostic interaction: the patient as a source of knowledge?

OBJECTIVE

To explore diagnostic interaction to understand more about why some problems appear medically unexplained.

DESIGN

A qualitative discourse analysis case study.

SETTING

Encounters between women patients and general practitioners in primary healthcare.

SUBJECTS

Microanalysis of two audiotaped consultations without a clear-cut diagnosis and opposing levels of mutuality between doctor and patient.

MAIN OUTCOME MEASURES

Descriptions of linguistic patterns in diagnostic interaction.

RESULTS

Two patterns were identified demonstrating how different ways of speech acts contribute or obstruct diagnostic interaction and common ground for understanding. To invite or reject the patient into/from the diagnostic process, and to recognize or stereotype the patient may impose on how illness stories are perceived as medically unexplained.

CONCLUSION

Making sense of illness can be enhanced by inviting and recognizing the patient's story.

The fibromyalgia diagnosis: hardly helpful for the patients? A qualitative focus group study

OBJECTIVE

To explore experiences and consequences of the process of being diagnosed with fibromyalgia.

DESIGN

Qualitative focus-group study.

SETTING

Two local self-help groups.

SUBJECTS

Eleven women diagnosed with fibromyalgia.

MAIN OUTCOME MEASURES

Descriptions of experiences and consequences of the process of being diagnosed with fibromyalgia.

RESULTS

Many participants had been suffering for years, and initial response of relief was common. For some, the diagnosis legitimized the symptoms as a disease, for others it felt better to suffer from fibromyalgia rather than more serious conditions. Nevertheless sadness and despair emerged when they discovered limitations in treatment options, respect, and understanding. Some patients keep the diagnosis to themselves since people seem to pay no attention to the name, or blatantly regard them as too cheerful or healthy looking. The initial blessing of the fibromyalgia diagnosis seems to be limited in the long run. The process of adapting to this diagnosis can be lonely and strenuous.

CONCLUSION

A diagnosis may be significant when it provides the road to relief or legitimizes the patient's problems. The social and medical meaning of the fibromyalgia diagnosis appears to be more complex. Our findings propose that the diagnosis was hardly helpful for these patients.

Women's strategies for handling chronic muscle pain: a qualitative study

OBJECTIVE

Medicine lacks good models for understanding and treating chronic muscle pain. The aim of this study was to explore whether participation in a treatment group for women with chronic muscle pain can help the participants to develop strategies to handle their chronic muscle pain.

METHODS

The study was carried out as a qualitative research project. Eight women completed a treatment programme consisting of movement training and group discussions. The qualitative data consisted of transcriptions from audio-taped individual interviews. The data material was analysed by systematic text condensation inspired by Giorgi.

RESULTS

All the women describe participation in the treatment group as useful. Their experiences could be categorized as follows: To know oneself, to negotiate with oneself and others, to be able to choose, and to be able to act.

CONCLUSION

The participants developed strategies for handling their chronic muscle pain. Both the women's new understanding of their chronic muscle pain and increased confidence in themselves were important. These phenomena can help women in their encounters with their surroundings, for example when consulting doctors. The doctor's awareness of the women's resources and their own mastering strategies may contribute to a new understanding of the disposing, triggering, and maintaining factors, and of the curative and health-promoting forces at work in those with chronic muscle pain.

Believing the patient with chronic pain: a review of the literature

The aim of this article is to review the literature on studies on the effect of having health professionals treat a patient's pain experience as credible and to propose considerations for nursing practice. A systematic literature search was performed via Cinahl, Medline, British Nursing Index, Cochrane and PsychINFO from 1970-2003 using the key words 'chronic pain', 'attitude', 'confirmation', 'listening to' and 'belief'. Study findings were reviewed in relation to the effect of 'being believed'. There are no studies that look exclusively at the effects of having a health professional believe a patient's reported pain experience; however, within the literature there are several references to the need to examine this phenomenon. Future research in this area is needed to provide direction for clinical practice for nurses in this aspect of chronic pain management.

'I am not the kind of woman who complains of everything': illness stories on self and shame in women with chronic pain

In this study, we explore issues of self and shame in illness accounts from women with chronic pain. We focused on how these issues within their stories were shaped according to cultural discourses of gender and disease. A qualitative study was conducted with in-depth interviews including a purposeful sampling of 10 women of varying ages and backgrounds with chronic muscular pain. The women described themselves in various ways as 'strong', and expressed their disgust regarding talk of illness of other women with similar pain. The material was interpreted within a feminist frame of reference, inspired by narrative theory and discourse analysis. We read the women's descriptions of their own (positive) strength and the (negative) illness talk of others as a moral plot and argumentation, appealing to a public audience of health personnel, the general public, and the interviewer: As a plot, their stories attempt to cope with psychological and alternative explanations of the causes of their pain. As performance, their stories attempt to cope with the scepticism and distrust they report having been met with. Finally, as arguments, their stories attempt to convince us about the credibility of their pain as real and somatic rather than imagined or psychological. In several ways, the women negotiated a picture of themselves that fits with normative, biomedical expectations of what illness is and how it should be performed or lived out in 'storied form' according to a gendered work of credibility as woman and as ill. Thus, their descriptions appear not merely in terms of individual behaviour, but also as organized by medical discourses of gender and diseases. Behind their stories, we hear whispered accounts relating to the medical narrative about hysteria; rejections of the stereotype medical discourse of the crazy, lazy, illness-fixed or weak woman.

It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors

In various studies during the last decade, women with medically unexplained disorders have reported negative experiences during medical encounters. Accounts of being met with scepticism and lack of comprehension, feeling rejected, ignored, and being belittled, blamed for their condition and assigned psychological explanation models are common. Women patients exerted themselves to attract the doctor's medical attention and interest, and were anxious to be considered as whiners or complainers. Here, we explore the nature of "work" done by the patients in order to be believed, understood, and taken seriously when consulting the doctor. A qualitative study was conducted with in-depth interviews including a purposeful sampling of 10 women of varying ages and backgrounds with chronic muscular pain. The main outcome measures were descriptions reflecting the patients' activities or efforts invested in being perceived as a credible patient. We focused on the gendered dimensions of the experiences. The women patients' accounts indicated hard work to make the symptoms socially visible, real, and physical when consulting a doctor. Their efforts reflect a subtle balance not to appear too strong or too weak, too healthy or too sick, or too smart or too disarranged. Attempting to fit in with normative, biomedical expectations of correctness, they tested strategies such as appropriate assertiveness, surrendering, and appearance. The most important activities or efforts varied. However, the informants were not only struggling for their credibility. Their stories illustrated a struggle for the maintenance of self-esteem or dignity as patients and as women. The material was interpreted within a feminist frame of reference, emphasising the relationship between dignity and shame, power and disempowerment for women patients' with medically unexplained disorders.