"Noticing the way that I'm Noticing Pain”: A Qualitative Analysis of Therapeutic Progression in Mindfulness-Oriented Recovery Enhancement for Patients with Lumbosacral Radicular Pain

Introduction : Mindfulness-based interventions (MBIs) are increasingly used to manage chronic pain, yet little is known about how participants develop the mindfulness skills that underlie their therapeutic benefit. Mindfulness-Oriented Recovery Enhancement (MORE) is a manualized MBI designed to foster adaptive attention and pain reappraisal. While previous research has demonstrated MORE's efficacy, the progression through which participants modify their relationship to pain remains unclear. To gain insight into individual-level experiences with MORE, we conducted a qualitative study that analyzed session recordings from a randomized controlled trial of MORE for patients with lumbosacral radicular pain (LRP) to better understand participants' evolving relationship with pain and attention. Methods : We conducted verbatim transcription and qualitative coding of 30 session recordings from the MORE program. Using iterative thematic analysis, we examined participant narratives during guided inquiry sessions to understand how they learned and applied mindfulness skills for pain management. Analysis focused on MORE’s model of processing, PURER (Phenomenology, Utilization, Reframing, Education, Reinforcement), and its role in facilitating therapeutic change. Results : Thematic analysis revealed four distinct stages in participants' progression and one common barrier: 1) Attention Dysregulation, 2a) Competency with Attention Regulation, 2b) Barrier – Experiential Avoidance, 3) Metacognitive Awareness, and 4) Pain Reappraisal. In addition, we found that some participants may engage in experiential avoidance, using their newfound attention skills to strategically avoid their pain experience. The PURER framework emerged as crucial in facilitating the cultivation of attention and adaptive engagement with pain experiences. Discussion : This study illuminates the progressive stages through which MORE participants develop adaptive relationships with chronic pain. While attention regulation skills are necessary, they initially may be used for avoidance. Therapeutic benefit appears to require guided progression through these stages with a skilled therapist. These findings suggest that mindfulness therapists should anticipate and work skillfully with initial avoidance tendencies while supporting participants' progression toward adaptive pain engagement. Conclusion : This study identified a four-stage progression in participants’ development of mindfulness skills for chronic pain: attention dysregulation, competency with attention regulation, metacognitive awareness, and pain reappraisal. Recognizing these stages can help clinicians anticipate common challenges, particularly the tendency to use mindfulness for avoidance rather than engagement. The PURER framework emerged as a critical mechanism by which therapists guide participants through these stages. These findings offer a clinically actionable model for assessing progress and tailoring mindfulness-based pain interventions to enhance therapeutic outcomes in patients with chronic lumbosacral radicular pain.