The prevalence of chronic pain (CP), persisting for more than 3 months, is rising globally (1). Recent pooled estimates suggest that 34% of adults in the United Kingdom currently experience chronic pain, with chronic widespread pain affecting 5.5 million (12%) of the British population (2). The impact of CP is multifactorial, and aside from its physical and psychological impact, it places significant social burden on People Living with Chronic Pain (PLwCP) and those around them. Factors such as pain-related loss of employment (3) and withdrawal from social engagement (4) are often linked with a significant deterioration in quality of life for PLwCP and their families (5). As a result, the social environment surrounding PLwCP has been widely investigated: where lack of social support is strongly associated with the genesis, maintenance, and worsening of pain symptoms for PLwCP (6), by contrast, positive social relationships and support from family and friends builds work ability, psychological well-being and quality of life (7, 8). The salience of social support when living with CP is therefore clearly evident and it is important that PLwCP are supported to maintain and/or build positive social relationships and social support structures.

Yet recent research has suggested that not all (positive) social support is equal. In line with the optimal matching hypothesis (9), when social support is optimally matched to a person's needs, then their ability to cope with pain is increased (7, 8). Indeed, CP patients report increased satisfaction and lower perceived stress when expressing their feelings to PLwCP who are experiencing similar health challenges (7, 10). However, when there is a mismatch between an individual's health status and the support which is received, this support can be experienced as “toxic positivity” or unsolicited advice (7). This may mean that individuals feel obligated to generate false positivity, expressed and experienced by people with and without CP as inauthentic, reducing individuals' desires to offer or accept social support in the future.

Though social support “matching” undoubtedly confers some benefits, it is possible that the associated outcomes may not be universally positive. Research has demonstrated that when individuals experiencing similar situations express their perspectives collectively, negative emotional contagion may occur (11). This phenomenon reflects the transfer of negative moods and emotions within a group (12), and the automatic synchronization and convergence of such emotions (13). By extension, in the context of chronic pain, this negative exchange spiral of emotions may increase perceived pain symptoms and lead to an overall decline in well-being. Though emotional contagion specifically within chronic pain settings has not yet been investigated, there is undoubtedly a need to better understand the formulation and presentation of person-to-person interactions in PLwCP. Chronic pain management interventions are typically undertaken in group contexts (14) and it is possible that group interactions within these settings may be jeopardizing rather than enhancing outcomes of pain management programmes.

An emerging method to understand emotion and pain experiences is a discursive approach (15). Discursive approaches move beyond pain self-report measures, to look at how “actions in talk” can better depict pain experiences (16). The analytic method of conversation analysis (CA) is a strong discursive approach which gathers information about normative patterns of speech in conversation and it analyses the extent to which deviant cases occur (17). CA is a novel way of understanding medical and clinical interactions (18), and has been widely used in clinical settings to understand communication between patients and clinicians (19–21).

To date, no studies have used CA to assess patient-to-patient interactions; instead, CA research typically focuses on clinician-patient interactions, addressing issues such as resistance (22) and advice giving (23) CA is often exploited to explore conversations on sensitive topics such as weight management (24) and cancer (25), but has not yet been extended to use in chronic pain. Consequently, the application of CA in a chronic pain setting may prove effective in understanding the conversation sequences and discursive organization presenting in interactions between PLwCP. CA may facilitate exploration of the conversational interactions involved in seeking social support from individuals also living with CP within a pain management group setting. This study therefore aimed to apply CA to patient-to-patient interactions in chronic pain management programmes, to investigate the conversational mechanisms involved in seeking mutual support between PLwCP.

The results of this study demonstrated that two key conversational mechanisms were active when PLwCP were interacting with each other and exploring their mutual experiences of chronic pain (see Figures 1, 2):

Results from this observational study demonstrated that patient-to-patient conversations within pain management settings were employing two specific interactional mechanisms, identified via conversation analysis. These approaches to communication were: (1) conversational humor and (2) a venting cycle. These patterns in speech demonstrated how CP patients expressed their pain experiences and supported each other through constructive interpersonal interactions. Both conversational mechanisms involved the use of humor, collaborating together to describe pain experiences with levity. These conversations allowed PLwCP space to express their negative emotions, before ending this cathartic vent with a light-hearted punchline, which served to pivot the conversation toward other contributors and new topics. Although the humor was targeting difficult experiences of pain and pain management, the positive reception and adoption of humor within the group indicated that the humor facilitated the discussion of sensitive topics in a socially supportive environment.

The results of this study showed how fundamental the use of humor is in interpersonal interactions, even within a pain management setting. The deliberate application of humor to difficult situations has been demonstrated in other chronic illness populations; after radiotherapy, humor enabled people with cancer to cope better with their health (38). Similarly, quantitative assessment of humor use within pain, has suggested that PLwCP may employ humor to gain perspective on their pain and distance themselves from their situation by accepting the negative emotions that common when living with chronic pain (39). In confirmation, a recent narrative review on pain and humor suggested that humor serves to improve pain coping and minimize emotional distress (40). Humor in pain management settings may therefore act as a method of bolstering pain-related resilience and reducing pain catastrophising (41). Certainly, in this study, the deliberate use of humor was evidenced through consistent use of jokes and delivery of punchlines, even when these may be least expected, for example, after venting and describing difficult pain-related situations. Finding the humor in chronic pain is indicative of highly subjective, black humor, which is mutually understood and facilitated by participants' common experiences, but which may not fully translate to others without pain or an understanding of chronic pain. So-called “black humor” or “gallows humor” is recognized as having therapeutic value, particularly when used by individuals facing trauma or challenging circumstances in health settings (42). Indeed, in clinical contexts, such self-deprecating humor has been found to boost psychological well-being, despite its dark(er) content (43), suggesting it is adaptive in the pain management context.

The theoretical underpinning of the humor evidenced in the current study provides an interesting disconnect between our findings and previous interpretations of humor in pain management. Previous research, using a cross-sectional quantitative assessment of humor, pain and psychological well-being has been interpreted as indicating that humor is a distancing mechanism, a way of making space between chronic pain and oneself as a method of self-protection (39). However, the real-life conversational mechanisms demonstrated in this study did not suggest that interactive humor was a distancing mechanism. Indeed, an approach-based pattern was found; in the naturalistic interactions we recorded, there was a clear willingness to “vent” by giving detailed descriptions about one's pain experience, setting up a conversational context in which PMP group members actively chose to enter into the discussion and to collaborate in joking about pain. This suggests a willingness to approach rather than avoid the pain situation that is described by their colleague and a willingness to approach one's own pain when venting.

The difference between our findings here and that of Ramírez-Maestre et al. (39) may be explained by the “optimal matching hypothesis” (9). In the current study, all participants already had a mutual understanding of chronic pain and therefore the shared pain experience was a commonality between the group, allowing for psychological safety in approaching this difficult topic (44) removing the need to employ distancing. Therefore, patient-to-patient interactions in PMPs were evidencing an affiliative humor style, using humor to enhance one's relationship with others (45). This is powerful evidence that interpersonal, conversational humor in PLwCP is not aggressive, self-enhancing, self-defeating or distancing. It is constructive, collaborative, communicative and creates warm appreciation of others within the group, respecting the shared mutual understanding of chronic pain. Further research is needed to establish whether this humor style only worked because of group dynamics or whether it can be identified more widely. Where “dark humor” is employed, there is the risk that such humor could be misconstrued, causing unease, alienation or even perceived insult (46). The participants in this study were all PLwCP, which provided a certain level of implicit understanding of pain experiences that is likely not there in interactions between different patient populations or between people with and without CP.

The prosocial nature of the humor demonstrated in this study was unusual in that it employed mutual sarcasm, with the sarcasm applied not to a person, but to the context under discussion-chronic pain itself. Wider literature suggests that the type of humor is important when addressing health conditions (47, 48) for example, mocking and sarcasm are typically viewed negatively (38). However, in this study, the participants used sarcasm that was received positively and was directed toward pain rather than a person or their behavior. The sarcasm highlighted the ridiculousness of the situation (for example, being prescribed numerous medications) rather than ridiculing the speaker, suggesting that the target of the humor may be more important compared to humor type in interactions between PLwCP. The current study demonstrated one incidence (Extract 3) when use of sarcasm came closer toward being associated with an individual, rather than pain more generally. In that instance, the healthcare professional stepped in to maintain the prosocial balance in the humor, though the participants in the conversation showed strong awareness of the need to keep their conversational humor inclusive. It is possible therefore that HCPs may benefit from additional awareness and training in the value of humor within the pain management setting, to respond to and encourage such humor effectively.

The venting cycle that was demonstrated in this research found that PLwCP were active listeners to their colleagues' distress, using positive minimal response (mmm, yeah) and interjecting shared experiences to demonstrate empathetic listening. This shows that group interactions in the PMP setting are building pain coping, as has also been shown in chronic pain support groups (41). Yet, the venting and the humor which concludes the vent cycle are not a distraction away from pain, posited as a primary theoretical explanation for the benefits of humor in pain management (40), nor are they methods of promoting cognitive reappraisal of pain (49). Instead, the venting cycle, is further evidence of the power of social support to improve pain coping and pain management (50). The vent is allowed to continue by the listeners, who help the speaker through the expression of their difficult experience. Therefore, the vent is acting as a method of emotion regulation, which can help to mediate the relationship between negative emotions and anxiety or depressive disorders (51).

Humorous interpersonal interactions about chronic pain act as an important forum for social support-building between members of a PMP. Such dynamic interactions referenced the mutual experience of chronic pain and fostered common humor, helping people living with chronic pain to make sense of their pain in a prosocial atmosphere. When negative emotions were strongly expressed through venting, responses were empathetic with active listening used to validate the negative emotions, allowing for a cathartic expression of personal challenges. Patient-to-patient interactions within the PMP were therefore strongly prosocial and mutually inclusive, evidencing that the socially communicative context fostered during PMPs has significant power to facilitate enhanced clinical outcomes and group cohesion.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by NHS Ethics REC: 13/WM/0214. The patients/participants provided their written informed consent to participate in this study.

KF and SP: conceptualization of research. KF: data collection. KF, KA, and AM: data analysis and drafting the manuscript. KF, KA, AM, and SP: editing and review of manuscript. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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