"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.

Objectives: Mindfulness-Oriented Recovery Enhancement (MORE) aims to foster adaptive attention and pain reappraisal. While research has demonstrated MORE's efficacy, the progression through which participants modify their relationship to pain remains unclear. To understand this process, we conducted a qualitative study with data from a clinical trial of MORE for patients with lumbosacral radicular pain (LRP). Method: Thirty session recordings from MORE were coded. Using thematic analysis, we examined therapeutic processing sessions to understand how participants learned and applied mindfulness to pain. Analysis focused on dialogue resulting from MORE's model of processing, Phenomenology, Utilization, Reframing, Education, Reinforcement (PURER). Results: Four stages and one barrier were identified: (1) Pain Vigilance and Attention Dysregulation, (2) Attention Regulation and its application to Experiential Avoidance, (3) Metacognitive Awareness, and (4) Pain Reappraisal. In addition, some participants engaged in experiential avoidance by using their newfound attention skills to avoid their pain experience. PURER emerged as crucial in facilitating adaptive pain engagement. Conclusions: The four-stage progression pattern identified here - the Vigilance-Avoidance Metacognition-Reappraisal (VA-MR) framework - may help clinicians anticipate challenges in mindfulness training. This study illuminates how MORE participants develop an adaptive relationship with chronic pain, and while attention regulation skills are necessary, they may initially be used for avoidance. Therapeutic benefit appears to require guidance through these stages by a skilled therapist who can navigate initial avoidance tendencies. These findings offer an actionable model for assessing progress and tailoring MBIs to enhance therapeutic outcomes.