"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

"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 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "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 Ryan S. Wexler, Wade Balsamo, Devon J. Fox, Danielle ZuZero, Anand Parikshak, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7104279/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Mar, 2026 Read the published version in Mindfulness → Version 1 posted You are reading this latest preprint version Abstract 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. back pain radiculopathy mindfulness non-pharmacologic management qualitative analysis longitudinal analysis Figures Figure 1 1. Introduction Chronic pain is a pervasive health issue affecting approximately 20% of adults in the United States (Yong et al., 2022 ). Among chronic pain conditions, lumbosacral radicular pain (LRP), commonly known as sciatica or spine related leg-pain, presents a particularly challenging clinical picture (Mahmutović et al., 2024 ; Schmid et al., 2023 ). LRP is characterized by pain, sensory loss, and motor/reflex abnormalities most commonly resulting from compression of the L4-S1 nerve roots (Tarulli & Raynor, 2007 ). This condition not only causes significant physical discomfort but also contributes to decreased quality of life (Konstantinou et al., 2013 ). Traditional approaches to managing LRP often involve pharmacological interventions, including opioid medications, which carry risks of dependence and abuse (Vowles et al., 2015 ). Considering these challenges, there is a growing interest in non-pharmacological, mind-body interventions for chronic pain management. Mindfulness-based interventions (MBIs) have shown promise in this regard, demonstrating efficacy in reducing pain severity and improving pain-related functioning (Hilton et al., 2017 ).While previous research has demonstrated the effectiveness of MBIs for chronic pain conditions (Hilton et al., 2017 ; Wexler et al., 2024 ), less is known about the psychological mechanisms and therapeutic progression through which participants develop adaptive relationships with pain. Mindfulness-Oriented Recovery Enhancement (MORE) represents a novel approach within the field of MBIs (Garland, Hanley, et al., 2022 ; Garland, 2024 ; Parisi et al., 2022 ; Wexler et al., 2024 ). MORE integrates mindfulness training with principles from cognitive-behavioral therapy and positive psychology to specifically target the dysregulation of reward processing and attentional bias towards pain-related cues that often characterize chronic pain conditions (Garland & Howard, 2013 ). The program aims to enhance participants' ability to notice and savor natural rewards while simultaneously developing a more adaptive relationship with pain sensations. Prior full-scale randomized controlled trials (RCTs) have demonstrated MORE’s efficacy for treating heterogeneous forms of chronic pain and reducing opioid use; in the largest such trial, MORE reduced opioid misuse by 45%, nearly tripling the effect of standard group therapy, while significantly decreasing pain severity and pain-related functional interference through a 9-month follow-up (Garland, Hanley, et al., 2022 ). A more recent early-stage randomized controlled trial examined MORE's efficacy specifically for LRP symptoms, and while quantitative outcomes demonstrated MORE's positive impact on pain intensity, understanding if and how participants’ relationship with pain changes throughout the intervention – requires qualitative investigation (Wexler, 2022 ; Wexler et al., 2024 ). A key component of MORE is its structured model of therapeutic processing, known as PURER: Phenomenology, Utilization, Reframing, Education/Expectancy, Reinforcement (Garland, 2013 , 2024 ). In each session, a trained clinician uses the PURER approach to process the in-session mindfulness practices via inquiry into phenomenology of the meditative experience; utilization of in-session meditative experiences to facilitate generalization of learning to coping with symptoms outside of the session; reframing challenges that arise during meditation as the practice of mindfulness; education about meditative phenomena and building positive therapeutic expectancy; and positive reinforcement for engaging in mindfulness practice attempts (see Table 2 ). PURER draws from behavioral change theory principles of selective reinforcement and successive approximation to shape participant responses to meditation practice towards the successful application of mindfulness toward pain relief and other therapeutic goals (e.g., emotion regulation, reduction of opioid use). This model guides participants through a process of exploring their pain experiences, reappraising their relationship to pain, and reinforcing adaptive coping strategies. However, despite the growing body of research supporting the efficacy of MORE for various chronic pain conditions, its specific impact on LRP and the psychological mechanisms through which it influences pain perception and pain management remain underexplored. Understanding the therapeutic progression fostered by the PURER approach is crucial for optimizing intervention delivery and supporting participants through common challenges. Previous research suggests that mindfulness can reduce pain-related suffering (McCracken et al., 2007 ); however the path to therapeutic benefit may not be linear, as research indicates that initial attempts at mindfulness practice may present challenges in implementation and understanding. In addition, prior work has revealed multiple complex interactions between mindfulness, pain catastrophizing, pain intensity, and fear-avoidance patterns. Schütze et al. previously showed that mindfulness acts as a moderator of the relationship between pain catastrophizing and fear-avoidance and that mindfulness also moderates the relationship between pain catastrophizing and pain intensity (Schütze et al., 2010 ; Wilson et al., 2023 ). This study analyzed session recordings from participants in the MORE arm of a randomized controlled trial for LRP patients. Our analysis focused on how participants described their experiences with mindfulness practice, pain perception, and the application of MORE skills in daily life. This study sought to address critical gaps in our understanding of how MBIs facilitate therapeutic change in chronic pain conditions. We aimed to identify the process by which MORE encourages a shift in pain perception that is often reported among individuals suffering with pain-related disability due to LRP. In addition, we hypothesized the presence of distinct stages in participants' progression through phenomenological inquiry that may elucidate the mechanisms through which mindfulness influences pain perceptions. Understanding how participants navigate and develop an adaptive relationship with pain could inform clinical practice and theoretical models of mindfulness-based pain management. 2. Methods 2.1 Ethical Considerations and Data Management The clinical trial in which this qualitative data was collected was approved by the Institutional Review Board of the National University of Naturopathic Medicine (IRB #: KP112720). To protect participant confidentiality, identifying information was removed from transcripts and participants were assigned pseudonyms. Audio recordings and anonymized transcripts were stored on encrypted servers accessible only to the research team. 2.2 Study Design and Sample This qualitative investigation analyzed recorded sessions from 37 participants receiving MORE as part of a randomized controlled trial for LRP (Wexler, 2022 ; Wexler et al., 2024 ). The parent study recruited participants aged 18–65 years who either had a physician-confirmed LRP diagnosis or reported chronic LRP symptoms with the presence of neuropathic pain on screening (painDETECT scores > 15). Exclusion criteria included recent epidural steroid injections (< 3 months), inability to complete 20 unassisted gait cycles, recent surgical interventions for back pain or radicular pain (< 6 months), an existing mindfulness practice, concurrent cancer diagnosis, and unmanaged psychotic disorders. 2.3 Data Collection and Preparation We analyzed 30 audio recordings from the 8-week MORE intervention, each consisting of 2-hour group sessions following the manualized MORE for Pain protocol (see Table 1 (Garland, 2013 , 2024 ; Wexler, 2022 )). All MORE sessions followed a similar structure which included: mindfulness of pain practice, practice debriefing, daily homework review, new psychoeducational content, experiential exercises, and a closing discussion. Recordings were transcribed verbatim using Whisper speech recognition software, with researchers manually verifying transcript accuracy. To reduce potential bias in analysis of participants’ progress through the program, transcripts stripped of session numbers and randomized before qualitative coding began. Table 1 MORE Session Topics Session 1 What is Pain and Why Can Mindfulness Help? Session 2 Automaticity in Chronic Pain Session 3 Mindful Reappraisal Session 4 Mindful Savoring Session 5 Relationship between Pain and Unhealthy Coping Mechanisms Session 6 Disrupting the Link between Stress and Pain Session 7 Pain and Thought Suppression, Mindfulness to Meaning and Interdependence Session 8 Review and Discussion of Maintaining a Mindfulness Practice 2.4 Qualitative Coding We employed thematic analysis throughout the qualitative coding process. At weekly meetings, RSW and WB discussed transcript excerpts allowing codes to arise from the data. A preliminary codebook was developed using terms from the MORE manual and MBI literature such as “chronic pain”, “guided inquiry”, “mindful reappraisal”, and “attention regulation”. This initial codebook was applied to a sample of seven transcripts which were coded independently and in-duplicate. After each transcript was coded, consensus meetings were held to refine the codebook and code definitions. Coding was completed using the Delve software ( Delve, a Cloud-Based CAQDAS Tool for Coding in Qualitative Research , 2025). To maintain methodological rigor, we implemented multiple validation strategies. Consensus meetings allowed for discussions about divergent interpretations of the data. In addition, we actively sought and analyzed negative cases - instances where participant experiences deviated from emerging patterns - to ensure our analysis captured the full range of participant experiences. Coding memos were used to document analytical decisions and emerging interpretations. Data triangulation included comparison with quantitative outcomes from the parent study and consultation with MORE therapists to verify interpretations of participant-therapist interactions (Carter et al., 2014 ). Once a refined version of the codebook had been developed and all transcripts were coded, codes were organized into themes, with supporting quotes cataloged for each theme. The research team then reviewed these themes against both the coded excerpts and complete dataset to ensure comprehensive representation of participant experiences. The resulting analysis provides a detailed account of participant experiences and therapeutic progression patterns. While our analysis was informed by prior research on mindfulness and chronic pain, our coding process remained inductive and data-driven. As themes coalesced, we identified consistent patterns in how participants described the development of mindfulness skills, which later informed our understanding of therapeutic progression. 2.5 PURER Framework of Therapeutic Processing The PURER model (Table 2 ) provides a framework for MORE therapists to engage participants in guided inquiry about their mindfulness practice (Garland, 2013 ). This systematic model of questioning was used after each mindfulness practice during weekly sessions to facilitate participants’ exploration and understanding of their pain experiences. The therapist’s role in this process is to support attention development through phenomenological inquiry about mindfulness experiences, validate participants’ challenges while reinforcing progress, educate participants about normal mind-wandering, and encourage participants to continue practicing despite difficulties. In our analysis, we used PURER to provide structure to the analytic approach of in-session qualitative data. Table 2 PURER Steps and Definitions PURER Step Definition Phenomenology Therapists used open-ended but directive questions to elicit detailed descriptions of participants' moment-to-moment experiences during mindfulness practices, with a focus on eliciting positive or therapeutic experiences. Participants where queried about the temporal sequence and unfolding of their meditative experiences. These inquiries focused on physical sensations, emotional responses, and cognitive processes (e.g., "What did you notice about your experience?" "Where did your attention go?"). This phenomenological data formed the foundation for subsequent components of the framework, particularly a starting point in discussion that could be followed by other participants. Utilization Therapists actively incorporated participants' reported experiences into teaching key concepts and skills for coping in everyday life. Participants were asked how they could use what the learned from the mindfulness practice session to address their symptoms in everyday life outside of the session. Reframing Reframing was facilitated through guided discussion of alternative interpretations of pain experiences and used as examples of the lesson being taught within the MORE session. Therapists helped participants examine their automatic pain-related thoughts and develop more adaptive perspectives. Therapists also reframed the inevitable challenges that arise during meditation as the practice of mindfulness. Education / Expectancy Educational elements were systematically integrated to help participants understand the relationship between attention, pain perception, and emotional responses. This included explanation of relevant neurobiological mechanisms of pain and the psychological principles underlying mindfulness practices. Importantly, therapists aim to build an expectation of therapeutic benefit in this step. Reinforcement Therapists consistently acknowledged and reinforced participants' efforts to engage with mindfulness practices and their emerging insights about pain management. This positive reinforcement aimed to strengthen pain coping strategies and maintain engagement with the intervention. This framework of in-session interviewing not only provided the structure for data collection and an intimate lens through which to examine participant experiences and progression through the intervention, but as session recordings were evaluated, the implementation of PURER emerged as an integral part of the skill development supporting therapeutic change. Before describing participants’ therapeutic progression, it is important to briefly introduce the specific mindfulness practice taught in MORE. A key practice in MORE is the “mindfulness of pain” technique, which goes beyond general mindful breathing. Participants are taught two complementary attentional strategies: “zooming out” and “zooming in.” Zooming out involves redirecting attention away from the pain (often toward the breath or body as a whole) to reduce emotional reactivity or distress. In contrast, zooming in guides participants to attend directly to the pain itself, observing its sensory features such as intensity, location, texture, and boundaries. Participants learn to decompose pain into component sensations (e.g., heat, tingling, pressure) and to explore surrounding areas for neutral or pleasant contrast. This practice facilitates a shift from affective interpretation to direct sensory awareness, supporting reappraisal and reducing suffering. Both techniques are introduced within the MORE program as therapeutic tools, helping participants build a more adaptive relationship to pain. 3. Results The final sample was predominantly white (81%) and female (70%), with a mean age of 48.59 years and a mean condition duration of 13.72 years. At baseline, participants had an Oswestry Disability Index score of 19.70 and a pain visual analogue scale score of 5.14 (0 = no pain; 10 = most pain); ( Wexler et al. 2024 )) All demographic characteristics can be found in Table 3 . Table 3 Demographic characteristics at baseline presented as mean (SD) or n (%) from Wexler et al. (Wexler et al. 2024 ) Demographics Total n = 37 Sex Male 11 (30%) Female 26 (70%) Race Anglo-American 30 Black 2 Asian - Hispanic/Latino 2 Middle Eastern 1 More than 1 race 1 Other 1 The qualitative analysis found four distinct stages and one common barrier of mindfulness skill development characterized by participants' progression through the MORE program: 1) attention dysregulation, 2a) competency with attention regulation, 2b) barrier – experiential avoidance, 3) metacognitive awareness, and 4) pain reappraisal. In addition, we found that the stepwise nature of PURER facilitated progression through these stages during the MORE program (Fig. 1 ). The following quotes describe progression through these stages. It is important to note that, just as with any new skill, learning mindfulness does not always occur in a linear fashion; we observed many participants still experiencing challenges in later weeks of the MORE program. 3.1 Stage 1: Attention Dysregulation Early sessions in the MORE program focus on building basic mindfulness skills. Here, participants expressed their initial challenges, which generally appear as difficulty maintaining attention – a phenomenon commonly seen in chronic pain patients (Alcon et al., 2025 ; Battison et al., 2023 ; Ibrahim & Hefny, 2022 ). Some participants expressed doubt about their capacity to successfully engage in mindfulness practice: "...maybe I had doubt early on because I have so many attention issues, [I doubted] if I would be able to do this practice well." [Cohort 1, Session 5] Participants consistently reported difficulties with basic attention regulation in early sessions, particularly around maintaining focus during meditation practices. "The most difficult part... I mean, I feel like it's this every time, is just sort of staying, like keeping my mind on track with it, just not getting distracted by other things" [Cohort 3, Session 3] MORE therapists deal with this common complaint by reframing the attentional lapse as the practice of mindfulness. This encourages participants to continue working towards the development of mindfulness as a skill by providing reinforcement that they are on the right track. Physical discomfort also affected participants’ ability to maintain attention. In particular, participants expressed that their pain made it challenging to be still during meditation: "...if I'm still, my body, the pain in the hips will flare up. So I'll have to move. And it's like a butterfly effect with my brain. Once I have that pain and I move, my focus is lost." [Cohort 3, Session 2] “ I went to the part that was painful. And I was okay there, but then I think it's, I don't know. I had to keep moving. I can’t, I can't lay still ." [Cohort 1, Session 4] In this first stage, participants demonstrated characteristic patterns of attention dysregulation that manifested as pain vigilance, or an inability to easily move their attention away from their pain experiences (Badiei et al., 2023 ). 3.2.a Stage 2: Competency with Attention Regulation As participants practiced breath awareness and mindfulness skills emerged, they noted qualitative shifts in their attention regulation abilities over time. The development of these skills was evidenced through multiple participant narratives that demonstrated increasingly sophisticated attentional capabilities: " There's less fight going on internally as far as the intention goes than it was four weeks ago. It's almost like a switch now. Whereas before, it was really back and forth, back and forth. And now it's operating much smoother ." [Cohort 1, Session 5] Looking back, some participants expressed a critical shift from avoidance-based coping strategies to an approach-oriented engagement with pain sensations: " I think for me [before the program], I would just do things to not feel the pain, ya know? I knew it was there all the time, but instead of focusing on it, this helped me go in, relieve it a little more and then let it go. Even though I still have it, but it’s not as bad ." [Cohort 1, Session 8] Over time, participants demonstrated general attention regulation across multiple domains: "When I first started… I was really scattered, and I had a hard time staying in tune with it. And this time, well, I really noticed the whole time, it's my ability to like jump in and get into that state and stay in that state better than before." [Cohort 1, Session 8] For example, this participant developed reduced mind wandering, suggesting improved focus; enhanced ability to “jump in” and enter meditative states, indicating improved attentional flexibility; and increased capacity to “stay in that state” and maintain attention over time, reflecting improved attention regulation. While these emerging skills marked important progress, they also introduced a new challenge: some participants used their enhanced attention to avoid pain rather than engage with it. 3.2.b Experiential Avoidance Once participants had developed an initial ability to regulate their attention and a basic competency with mindfulness skills, a tendency emerged in some participants to use these skills for cognitive avoidance, avoiding or escaping distressing thoughts or experiences, rather than engagement with pain experiences. "It was hard for me to get past the pain that I have. I kept trying to circle back and try to make it go away, but I was having a really hard time… I'm trying to not think about it. Just think about the breathing and staying with the breathing." [Cohort 1, Session 7] In some cases, this distancing approach could be adaptive to provide individuals the time and attention required to approach their discomfort in a therapeutic manner (Folkman & Moskowitz, 2004 ; Sagui-Henson, 2017 ). As participants gained basic attention control, many initially employed these skills to avoid pain experiences rather than engage with them mindfully, which manifested as an experiential avoidance: “the attempt to avoid internal experiences (e.g. thoughts, feelings, physical sensations) that are experienced as negative (Mohr, Matthew, 2025).” This psychological resistance in fear of the pain experience revealed a complex interplay between attention regulation and pain processing, which manifested as a barrier within the program. " So I'm trying to just listen to you and ignore [the pain]... Ignoring the pain instead of going into the pain. It makes it hurt more…When I ignore the pain, it makes it hurt less ." [Cohort 1, Session 6] Some participants described strong psychological resistance to pain exposure: " I'm just kind of agitated, it's like my mind is in an agitated state when I'm just laying there. And so part of me feels like, I was dropping in [to the meditation], but I have a lot on my mind. And I notice myself not wanting to do it… feeling very much wanting to distract myself." [Cohort 2, Session 3] Others noted how when they pay attention to their pain after being attentive to something else, that’s when the pain hurts more. “Now that we're talking about it again though my leg will start firing. It's just when I think about it or talk about it too much…I think it's something I made up but sometimes it will hurt more." [Cohort 2, Session 5] Other participants embraced the ability to use mindfulness to re-orient attention away from pain: "It [mindfulness] becomes like a superpower... to fly you somewhere else away from your sorrows and away from the pain" [Cohort 1, Session 7] These avoidant tendencies led to a common misunderstanding of the therapeutic practice of mindfulness as a process of escape from pain rather than reprocessing and reappraisal of pain sensations, which highlights the importance of skilled guidance and questioning through early stages of mindfulness-based pain management and suggests the need for careful scaffolding of attention regulation skills that work through these challenges. Collectively, these narratives document a developmental progression in attention regulation characterized by reduced mind wandering, increased volitional control, enhanced metacognitive awareness, and greater efficiency in attentional processes. This stage represents a critical transition point where basic attentional competencies are established, creating the foundation for the more advanced metacognitive skills to emerge. 3.3 Stage 3: Metacognitive Awareness When participants engaged in continued practice and guidance after mindfulness sessions, they began to display a more nuanced and adaptive capacity to process their pain perceptions by shifting from affective to sensory processing of pain sensations. Through metacognitive awareness of avoidant tendencies, participants were able to begin engaging in healthy forms of pain reappraisal – coming to view pain as an innocuous sensation – and some participants even reported joy in reconnecting with physical sensations: " [It was] quite enjoyable to be able to just kind of soak in and just kind of feel or experience what my body's experiencing because I've really kind of been detached and, more trying to make it go away and not really focusing on feeling it and trying to figure out where it's at. So it was good to be able to just recognize what my body's doing ." [Cohort 2, Session 4] Participants also seemed to overcome avoidant tendencies: "I think like the times when I've noticed I can relax around it, it helps with the pain. Because then I get to notice it's shifting. I'm not bracing against it or like trying to avoid it. " [Cohort 2, Session 1] The therapeutic benefit of metacognitive awareness led to clear shifts in participants' relationship with pain and improved physical function. A key shift involved participants developing the ability to observe their own mental processes and the impact of these processes on physical sensations. 3.4 Stage 4: Pain Reappraisal As the metacognitive process of looking at the current appraisal of experience can be utilized to re-appraise the experience of pain, participants begin reinterpreting the signals and adapting their relationship with pain. When participants were able to bring mindful awareness to areas of their body with pain through the “mindfulness of pain” technique taught in MORE enabled them to shift from affective to sensory processing of the pain experience (Garland, Roberts, et al., 2022 ), and they expressed a shift in their pain experience: “The more I focused on the breath at that specific point it just seemed like the intensity of the pain decreased into a cool feeling... to where I could kind of calm things down by utilizing the breath." [Cohort 4, Session 3] "When I went into the pain part of it, it was very jagged and sharp and hot and red... as I breathed more into it, it got less sharp, more of a dull" [Cohort 1, Session 7] We observed that some participants used reappraisal to change their relationship to pain entirely and to distinguish their identity from that of their pain experience: "I have to redefine my definition of pain... that's kind of what I've been set out to do is to redefine my definition of pain and not let it define me and control me and, you know, keep me just useless." [Cohort 1, Session 6] Participants reported fundamental changes in how they experienced and related to pain: "It feels like a sense of freedom really, you know, before you feel almost like you are getting a life sentence, like it's not going to end. Yeah, it's really, I feel a little bit like I have a new lease on life, endless of a thought of a life sentence, you know, which is really freeing, which is awesome. And I'm ready to like mentally I'm ready to take off and go running not quite physically though. So like my new lease on life is pushing me through a little bit more for sure, but then maybe at the same time pushing me a little too far at times." [Cohort 1, Session 8] "[I’m] noticing the way that I'm noticing pain... I feel like my relationship to it is changing. Which is great... I noticed that like today, I was walking. And, I don't remember the last time I walked and like, didn't immediately notice pain. I walked out of my house. And, and I think I had gone like a block and a half. And I was like, oh my gosh, like I don't, I'm not experiencing the same kind of pain." [Cohort 2, Session 3]f 3.5 The PURER Framework Facilitates Skill Development in Metacognitive Awareness We observed that skillful and systematic implementation of MORE’s guided inquiry process, PURER, supported participants in developing an adaptive relationship to their pain. Rather than simply teaching mindfulness techniques, therapists used PURER to help participants navigate challenges and develop increasingly nuanced relationships with pain experiences. In early stages, where participants struggled with basic attention regulation, therapists asked participants to describe their phenomenology, or moment-to-moment experience, to help participants investigate their meditation. Once participants had discussed what occurred for them during the practice session, therapists could use the participant’s experience as an example of an important concept being taught. This example, from the first session of the program, describes a participant who was prompted to report novel insights about their anticipations of the pain experience: Therapist: “ I was wondering if maybe you could zoom into a particular part of the meditation when that was happening and tell me how that happened with you and your mind and your breath.” Participant: " Every part of the body that we went to, my body, like, I felt more pain... it wasn't like constant, and it wasn't like... excruciating. it was just like, ‘Oh, you're noticing me and here I am’... I noticed like tension right here as you were approaching that... and I was like, that's anticipation... my brain is already deciding that it's kind of hurt before I even get there . So I actually tried to relax right here because I felt myself doing that. And I feel like that actually helped." [Cohort 2, Session 1] As participants began showing capacity for metacognitive awareness, therapists used phenomenological inquiry to deepen this emerging skill. The therapist reinforced this metacognitive observation while helping utilize it for pain management. Therapist: “What did you enjoy about today's practice?” Participant: “I'm really relaxed. A lot less pain.” Therapist: “Good, that's fantastic. When did that start for you in the meditation, [participant name]?” Participant: “Um, I went deep in, came back out, and went deep in. Each time it was a little less.” Therapist: “So you found that every time you went back to observe the pain, there was a little bit less there to notice?” Participant: “Mmhm. Yeah. It got softer and softer. Not as deep.” Therapist: “That's fantastic. I want to also take some time today, as we are debriefing that experience to focus or reflect on how things have changed over the course of these 8 weeks, 9 weeks now. How does that compare to some of the earlier experiences you had in the program? Do you find that the pain went away quicker? Or did it linger about as long as it used to but you were just more aware of it?” Participant: “ I think for me, I would just do things to not feel the pain, ya know? I knew it was there all the time, but instead of focusing on it, this helped me go in, relieve it a little more and then let it go. Even though I still have it, but its not as bad.” [Cohort 1, Session 8] In general, it appeared that the value of PURER is engrained in how its components worked together to support mindfulness skill development. As participants developed basic attention skills, but showed avoidance tendencies, therapists used phenomenological inquiry to help participants recognize and investigate their avoidance. Rather than criticizing avoidance, therapists used reframing and education to help participants understand its limitations while reinforcing their growing skillset. The systematic nature of PURER helped ensure key therapeutic elements were consistently present, while its flexibility allowed adaptation to participants' current stage and specific challenges. The framework particularly excelled at helping participants move from avoidance to engagement through careful phenomenological inquiry, strategic reframing, and consistent reinforcement of pain education in the MORE program. This structured and responsive guidance appears crucial for realizing therapeutic benefits from mindfulness-based pain management programs such as MORE. 4. Discussion By qualitatively analyzing audio recordings of MORE sessions, this study offers a unique perspective on the lived experiences of individuals with LRP as they begin a new mindfulness practice. This approach allowed us to capture the nuances of participants' evolving relationship with pain in real-time, providing valuable insights into the therapeutic process facilitated by MORE. These findings highlight a systematic progression in how participants develop adaptive relationships with pain through mindfulness practice. An important finding in this work was that the process of mindfulness-skill building was not unidirectional. Participants appeared to move between stages of skill development from week-to-week and even from meditation-to-meditation within a single weekly session. Participants’ pain experiences in meditation appear to lie along a spectrum on which skill development occurs over time, but challenging experiences, such as difficulty with attention regulation, can continue to occur after weeks of practice. Our findings extend beyond previous research by illuminating both the challenges and transformative processes that can occur during mindfulness-based pain management interventions. 4.1 Key Findings and Theoretical Implications Although the stages are presented linearly for clarity, they reflect themes that arose inductively through qualitative coding. Participants often moved fluidly between these phases, and our analytic structure was developed to reflect the complex, nonlinear nature of their therapeutic progression. Our findings reveal an important paradox regarding the relationship between attention regulation strategies and functional outcomes in early mindfulness skill development. While participants successfully developed basic attention regulation abilities, they often deployed these skills for experiential avoidance rather than engagement with the experience of pain. This pattern aligns with Hayes' theory of experiential avoidance (Hayes et al., 1996 ; Hayes-Skelton & Eustis, 2020 ). 4.1.1 The Dichotomy of Pain and Disability Our findings also highlight a critical observation from the parent clinical trial: while MORE produced a significant reduction in pain intensity, these improvements did not translate to corresponding reductions in disability in this trial (Wexler et al., 2024 ). The discrepancy between changes in pain intensity reduction and disability presents an important theoretical and clinical question that our qualitative analysis begins to address. We observed participants demonstrating two distinct approaches for attending to pain management through mindfulness: avoidance-based attention regulation and metacognitive awareness-based attention regulation. This dichotomy warrants critical examination within the context of disability outcomes. Participants in the avoidance stage successfully employed attention regulation techniques to reduce pain intensity, as evidenced by statements like: " When I ignore the pain, it makes it hurt less" [Cohort 1, Session 6]. However, this strategy may create a therapeutic “ceiling” regarding improvements in disability. While momentary pain reduction occurs, participants may remain unable to effectively direct their attention towards the affected areas when necessary, potentially maintaining disability levels despite a reduction in pain (Suso-Ribera et al., 2019 ; Zale et al., 2013 ). Participants who developed metacognitive awareness often reported awareness of pain sensations but demonstrated improvements in disability. One participant noted, "I walked out of my house... and I think I had gone a block and a half. And I was like, ‘Oh my gosh, like I don't, I'm not experiencing the same kind of pain!’" [Cohort 2, Session 3]. This suggests that while the sensory dimension of pain may persist, one’s affective response to pain and one’s relationship to the pain sensation is malleable, resulting in reduced disability. In MORE, patients are taught unique mindful breathing and body scan meditations designed to decompose the pain experience into its constituent sensations (e.g., heat, tightness, tingling), as well as to increase awareness of the center, edges, and permeability (versus solidity) of these sensations, and any adjacent or distal pleasant sensations. This practice of cultivating mindful awareness of pain may decrease emotional reactivity to pain and thereby decrease pain intensity. Moreover, this practice may disentangle self-referential processes from pain-related sensory input, an therapeutic approach supported by previous neurobiological research on the relationship between pain and participants’ sense of self (Riegner et al., 2023 ; Zeidan et al., 2015 , 2019 ). This observed dichotomy has significant implications for understanding therapeutic mechanisms in MBIs. Although initially learning to orient attention away from pain via mindful breathing may produce analgesic effects (Zeidan et al., 2011, 2015 ), the development of pain tolerance through directing meta-awareness towards pain – rather than experiential avoidance – may represent a more sustainable pathway to improvements in pain-related disability. Our findings suggest that the ability to direct attention towards pain when necessary, while maintaining an emotional equilibrium, typically referred to as “equanimity” within the context of meditation, may be important for achieving reductions in disability. These observations help contextualize the relationship between pain intensity and disability measured in the parent trial (Wexler et al., 2024 ) in which pain intensity was reduced while disability was not. However, it should be noted that prior full-scale RCTs have demonstrated that MORE significantly decreases pain-related functional interference, including measures of physical, social, and occupational function (Garland et al., 2014 , 2024 ; Garland, Hanley, et al., 2022 ). These conflicting results suggests further investigation into pain-related attention is warranted. 4.1.2 Phenomenological Inquiry Facilitates Metacognitive Development The PURER framework appeared to be particularly valuable in our study in facilitating the transition from avoidance-based pain management (which may reduce intensity but maintain disability) to metacognitive awareness-based pain management (which may maintain awareness of pain sensations while reducing disability). PURER emerged as crucial in facilitating the transition from avoidance to engagement with the experience of pain. This structured approach to inquiry helped participants move beyond initial avoidance tendencies towards a therapeutic engagement with their pain experience: " noticing the way that I'm noticing pain... I feel like my relationship to it is changing " [Cohort 2 Session 3]. This transformation suggests that therapist guidance through the PURER framework may be essential for realizing therapeutic benefits from MORE. In addition, the valuable role of the therapist highlights the importance of maintaining fidelity to the MORE program when delivering the intervention (Hanley et al., 2020 ). Finally, participants developed an increasing metacognitive awareness of their experience of pain. The progression from basic attention regulation to complex reappraisal is evident in multiple participants’ narratives. This development of metacognitive skills appears to be a key mechanism in transforming participants' relationship with pain and is taught to MORE participants using the skill of mindful reappraisal of pain. 4.2 Clinical Implications Clinicians should anticipate that patients with LRP may initially use mindfulness skills for experiential avoidance of their pain experience. The data suggests that acknowledging and working skillfully with avoidance, rather than treating it as failure, may be crucial for therapeutic progress. Early identification of avoidance patterns can help therapists guide participants towards greater engagement with their pain experience. Our findings also highlight the importance of carefully scaffolding the transition from basic attention training to mindful exposure to pain. The challenges documented in our analysis, such as "I just had a hard time getting settled... I couldn't get comfortable" [Cohort 1 Session 4], suggest the need for a gradual progression and robust support during this phase. Finally, the success of the PURER model in facilitating change suggests the importance of maintaining fidelity to this structured approach to therapeutic processing. Therapists should be trained to skillfully implement each component of PURER, using them systematically to support participants’ progress through MORE. As facilitators learn to deliver MORE and apply the PURER model, the MORE Fidelity Measure should be used to ensure therapist competence and adherence to the model (Hanley & Garland, 2021 ). 4.3 Interpretation of Findings in Relation to Existing Literature Our results align with and extend previous research on the use of MBIs for chronic pain. The shifts in pain perception reported by our participants, characterized by increased metacognitive awareness, reappraisal of pain sensations, and a move towards acceptance, support the notion that mindfulness practices can alter the cognitive and affective dimensions of pain, even when sensory aspects persist (Kabat-Zinn, 1982 ). In addition, the present results provide a detailed account of how metacognitive awareness develops over time and its specific application to LRP symptoms. Participants were able to observe their pain with greater detachment, a key psychological mechanism of mindfulness interventions called decentering (Hanley et al., 2020 ; Hick & Chan, 2010 ). The process of mindful reappraisal of pain sensations (Garland, Roberts, et al., 2022 ) observed in our study extends beyond simple distraction techniques often used in pain management programs. Instead, it involves a sophisticated re-evaluation of the pain experience, consistent with previous research (Ashar et al., 2022 ; Schütze et al., 2010 ). In addition, the observed shift from experiential avoidance to greater acceptance of pain aligns with the psychological flexibility model underlying Acceptance and Commitment Therapy (ACT) for chronic pain (McCracken et al., 2007 ; Vowles et al., 2015 ). However, the pain relieving effects of MORE have been shown to be statistically mediated by reinterpretation of pain as innocuous sensation (Garland et al., 2014 ; Garland, Roberts, et al., 2022 ), demonstrating that MORE operates through mechanisms other than acceptance through its integration of mindfulness meditation, reappraisal, and savoring practices. 4.4 Strengths, Limitations, and Future Directions A key strength and novel aspect of our study is the use of session recordings for qualitative analysis. This approach allowed us to capture the dynamic, moment-to-moment experiences of participants as they engaged with the MORE program, providing a level of detail and immediacy often missing from retrospective interviews or quantitative measures. The analysis of session recordings revealed the nuanced ways in which the PURER model guided participants' exploration and processing of their pain experiences. These findings contribute to our understanding of the specific components of MORE that may drive its therapeutic effects, addressing calls in the literature for greater specificity in understanding the active ingredients of MBIs (Gordon, 2017 ; Mohr et al., 2025 ). Our study also provides insights into the challenges and barriers faced by individuals with LRP in engaging with mindfulness practices. These findings can inform the refinement of MBIs to better address the specific needs of this population, potentially improving adherence and outcomes. Finally, our qualitative findings are corroborated by quantitative data from our previous publications indicating that participants experienced increases in scores on both the Mindful Reappraisal of Pain Sensations scale and the Five Facet Mindfulness Questionnaire - a measure of trait mindfulness (62.79% and 8.41% increases, respectively) (Wexler et al., 2024 ). While our study provides valuable insights, it has important limitations. First, our analysis focused on session recordings, where the virtual delivery format may have influenced participant experiences and therapist-participant interactions. Future research should examine whether similar progression patterns emerge within in-person settings. Second, this study only examined participant experiences with meditation during the MORE program and did not collect data on how participant mindfulness experiences may have changed after completing the intervention. Finally, while our analysis identified clear progression patterns, individual variations in this progression warrant further investigation. Due to the group design of this study, we were not able to identify specific participants on the audio recordings and track their progression over the course of the program. Rather, we were identifying shifts in an entire cohort’s understanding of MORE concepts from week-to-week via longitudinal qualitative analysis (Grossoehme & Lipstein, 2016 ). The four-stage progression model identified in this study may serve as a foundation for future efforts to track therapeutic progress more efficiently. With recent advances in artificial intelligence, researchers are beginning to explore whether large language models can help analyze qualitative data, such as session transcripts, in a more automated way. Early studies have shown that this approach is feasible (Lennon et al., 2021 ). Building on these developments, future research could use clearly defined therapeutic stages, like those described here, to support structured, theory-driven analysis of participant experiences. This could make it easier to refine and improve mindfulness-based interventions, even in small studies. Our findings suggest several promising directions for future research. The stages of skill development that we identified may be associated with important clinical outcomes, such as kinesiophobia or disability. Future studies might also examine factors that facilitate or impede progression through these stages. Assessing these stages throughout intervention delivery, as is done in iterative user-/human-centered design (Alwashmi et al., 2019 ), could allow the development of more personalized teaching and therapy strategies. Studies that aim to build on this work should consider investigating strategies to mitigate the tendency towards experiential-avoidance early in the program and attempt to assess a participant’s progression through the various stages of mindfulness skill development in real time. 5. Conclusion This qualitative study identified a four-stage progression in mindfulness skill development among individuals with lumbosacral radicular pain: attention dysregulation, competency with attention regulation, metacognitive awareness, and pain reappraisal. These stages provide a framework for understanding common challenges and therapeutic opportunities in mindfulness-based pain interventions. Crucially, the PURER model of guided inquiry facilitated this progression, helping participants move from avoidance toward adaptive engagement with pain. These findings offer a clinically actionable model for tailoring instruction, reinforcing the importance of therapist skill and program fidelity. As nonpharmacologic strategies for chronic pain evolve, incorporating structured, stage-informed guidance into interventions like MORE may improve outcomes for patients with LRP and related conditions. Declarations Competing Interests Eric Garland, PhD, LCSW is the Director of UCSD ONEMIND (Optimized Neuroscience-Enhanced Mindfulness Intervention Development). UCSD ONEMIND provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers. Dr. Garland also receives royalties from the sale of books related to MORE. Dr. Garland is also a consultant and licensor to BehaVR, LLC. Author Contribution RSW and WB were responsible for drafting the initial version of the manuscript. RSW, DJF, DZ, ART, SK, JR, and CKP were responsible for data collection. RSW, AP, ART, HLC, TK, SDM, RB, DAH, HZ, and CKP were responsible for the design of the parent trial in which the present data were collected. EG provided critical edits on the manuscript consistent with MORE’s theoretical framework. All authors approved the final version of the manuscript. Data Availability The data that support the findings of this study are available from the corresponding author, RSW, upon reasonable request. References Alcon, C., Krieger, C., & Neal, K. (2025). The Relationship Between Pain Catastrophizing, Kinesiophobia, Central Sensitization and Cognitive Function in Patients with Chronic Low Back Pain. The Clinical Journal of Pain . https://doi.org/10.1097/AJP.0000000000001293 Alwashmi, M. F., Hawboldt, J., Davis, E., & Fetters, M. D. (2019). The Iterative Convergent Design for Mobile Health Usability Testing: Mixed Methods Approach. JMIR mHealth and uHealth , 7 (4), e11656. https://doi.org/10.2196/11656 Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2022). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain. JAMA Psychiatry , 79 (1), 1–12. https://doi.org/10.1001/jamapsychiatry.2021.2669 Badiei, F., Brewer, B. W., & Van Raalte, J. L. (2023). Associations of Pain Vigilance and Past and Current Pain with Kinesiophobia after Sport Injury in Current and Former Athletes from Iran and the United States. Journal of Functional Morphology and Kinesiology , 8 (3), 117. https://doi.org/10.3390/jfmk8030117 Battison, E. A. J., Brown, P. C. M., Holley, A. L., & Wilson, A. C. (2023). Associations between Chronic Pain and Attention-Deficit Hyperactivity Disorder (ADHD) in Youth: A Scoping Review. Children , 10 (1), 142. https://doi.org/10.3390/children10010142 Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of triangulation in qualitative research. Oncology Nursing Forum , 41 (5), 545–547. https://doi.org/10.1188/14.ONF.545-547 Delve, a cloud-based CAQDAS tool for coding in qualitative research (Version 2086). (2025). [Computer software]. Twenty to Nine LLC. https://delvetool.com/ Folkman, S., & Moskowitz, J. T. (2004). Coping: Pitfalls and promise. Annual Review of Psychology , 55 , 745–774. https://doi.org/10.1146/annurev.psych.55.090902.141456 Garland, E. L. (2013). Mindfulness Oriented Recovery Enhancement . NASW Press. Garland, E. L. (2024). Mindfulness-oriented recovery enhancement: An evidence-based treatment for chronic pain and opioid use . The Guilford Press. Garland, E. L., Hanley, A. W., Nakamura, Y., Barrett, J. W., Baker, A. K., Reese, S. E., Riquino, M. R., Froeliger, B., & Donaldson, G. W. (2022). Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care. JAMA Internal Medicine , 182 (4), 407–417. https://doi.org/10.1001/jamainternmed.2022.0033 Garland, E. L., & Howard, M. O. (2013). Mindfulness-Oriented Recovery Enhancement Reduces Pain Attentional Bias in Chronic Pain Patients. Psychotherapy and Psychosomatics , 82 (5), 311–318. https://doi.org/10.1159/000348868 Garland, E. L., Manusov, E. G., Froeliger, B., Kelly, A., Williams, J. M., & Howard, M. O. (2014). Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial. Journal of Consulting and Clinical Psychology , 82 (3), 448–459. https://doi.org/10.1037/a0035798 Garland, E. L., Nakamura, Y., Bryan, C. J., Hanley, A. W., Parisi, A., Froeliger, B., Marchand, W. R., & Donaldson, G. W. (2024). Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial. The American Journal of Psychiatry , 181 (2), 125–134. https://doi.org/10.1176/appi.ajp.20230272 Garland, E. L., Roberts, R. L., Hanley, A. W., Zeidan, F., & Keefe, F. J. (2022). The Mindful Reappraisal of Pain Scale (MRPS): Validation of a New Measure of Psychological Mechanisms of Mindfulness-Based Analgesia. Mindfulness . https://doi.org/10.1007/s12671-022-02034-y Gordon, W. V. (2017). Exploring the Applications of Second-Generation Mindfulness-Based Interventions for . Grossoehme, D., & Lipstein, E. (2016). Analyzing longitudinal qualitative data: The application of trajectory and recurrent cross-sectional approaches. BMC Research Notes , 9 (1), 136. https://doi.org/10.1186/s13104-016-1954-1 Hanley, A. W., Bernstein, A., Nakamura, Y., Hadash, Y., Rojas, J., Tennant, K. E., Jensen, R. L., & Garland, E. L. (2020). The Metacognitive Processes of Decentering Scale: Development and Initial Validation of Trait and State Versions. Psychological Assessment , 32 (10), 956–971. https://doi.org/10.1037/pas0000931 Hanley, A. W., & Garland, E. L. (2021). The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): Development and Validation of a New Tool to Assess Therapist Adherence and Competence. Journal of Evidence-Based Social Work (2019) , 18 (3), 308–322. https://doi.org/10.1080/26408066.2020.1833803 Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experimental avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology , 64 (6), 1152–1168. https://doi.org/10.1037//0022-006x.64.6.1152 Hayes-Skelton, S. A., & Eustis, E. H. (2020). Experiential avoidance. In Clinical handbook of fear and anxiety: Maintenance processes and treatment mechanisms (pp. 115–131). American Psychological Association. https://doi.org/10.1037/0000150-007 Hick, S. F., & Chan, L. (2010). Mindfulness-Based Cognitive Therapy for Depression: Effectiveness and Limitations. Social Work in Mental Health , 8 (3), 225–237. https://doi.org/10.1080/15332980903405330 Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A. R., Shanman, R. M., Sorbero, M. E., & Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine , 51 (2), 199–213. PubMed. https://doi.org/10.1007/s12160-016-9844-2 Ibrahim, M. E., & Hefny, M. A. (2022). Central sensitization and adult attention deficit hyperactivity disorder in medical students with chronic back pain: A cross-sectional study. Egyptian Rheumatology and Rehabilitation , 49 (1), 24. https://doi.org/10.1186/s43166-022-00124-2 Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry , 4 (1), 33–47. https://doi.org/10.1016/0163-8343(82)90026-3 Konstantinou, K., Hider, S. L., Jordan, J. L., Lewis, M., Dunn, K. M., & Hay, E. M. (2013). The impact of low back-related leg pain on outcomes as compared with low back pain alone: A systematic review of the literature. The Clinical Journal of Pain , 29 (7), 644–654. https://doi.org/10.1097/AJP.0b013e31826f9a52 Lennon, R. P., Fraleigh, R., Van Scoy, L. J., Keshaviah, A., Hu, X. C., Snyder, B. L., Miller, E. L., Calo, W. A., Zgierska, A. E., & Griffin, C. (2021). Developing and testing an automated qualitative assistant (AQUA) to support qualitative analysis. Family Medicine and Community Health , 9 (Suppl 1), e001287. https://doi.org/10.1136/fmch-2021-001287 Mahmutović, E., Safiye, T., Biševac, E., Ajdinović, A., Salihagić, Z., Minić, S., & Dolićanin, Z. (2024). Quality of Life and Functional Status of Patients with Lumbar Radiculopathy. Iranian Journal of Public Health , 53 (8), 1837–1846. https://doi.org/10.18502/ijph.v53i8.16289 McCracken, L. M., Gauntlett-Gilbert, J., & Vowles, K. E. (2007). The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability. PAIN , 131 (1), 63. https://doi.org/10.1016/j.pain.2006.12.013 Mohr, E., Matthew, S., Narisetti, L., Duff, C., & Schoenberg, P. (2025). Cognitive mechanisms of mindfulness-based pain management in chronic pain. Social Sciences & Humanities Open , 11 , 101261. https://doi.org/10.1016/j.ssaho.2024.101261 Parisi, A., Roberts, R. L., Hanley, A. W., & Garland, E. L. (2022). Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials. Mindfulness . https://doi.org/10.1007/s12671-022-01964-x Riegner, G., Posey, G., Oliva, V., Jung, Y., Mobley, W., & Zeidan, F. (2023). Disentangling self from pain: Mindfulness meditation-induced pain relief is driven by thalamic-default mode network decoupling. Pain , 164 (2), 280–291. https://doi.org/10.1097/j.pain.0000000000002731 Sagui-Henson, S. J. (2017). Cognitive Avoidance. In V. Zeigler-Hill & T. K. Shackelford (Eds.), Encyclopedia of Personality and Individual Differences (pp. 1–3). Springer International Publishing. https://doi.org/10.1007/978-3-319-28099-8_964-1 Schmid, A. B., Tampin, B., Baron, R., Finnerup, N. B., Hansson, P., Hietaharju, A., Konstantinou, K., Lin, C.-W. C., Markman, J., Price, C., Smith, B. H., & Slater, H. (2023). Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. Pain , 164 (8), 1693–1704. https://doi.org/10.1097/j.pain.0000000000002919 Schütze, R., Rees, C., Preece, M., & Schütze, M. (2010). Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain. Pain , 148 (1), 120–127. https://doi.org/10.1016/j.pain.2009.10.030 Suso-Ribera, C., Camacho-Guerrero, L., Osma, J., Suso-Vergara, S., & Gallardo-Pujol, D. (2019). A Reduction in Pain Intensity Is More Strongly Associated With Improved Physical Functioning in Frustration Tolerant Individuals: A Longitudinal Moderation Study in Chronic Pain Patients. Frontiers in Psychology , 10 , 907. https://doi.org/10.3389/fpsyg.2019.00907 Tarulli, A. W., & Raynor, E. M. (2007). Lumbosacral radiculopathy. Neurologic Clinics , 25 (2), 387–405. PubMed. https://doi.org/10.1016/j.ncl.2007.01.008 Vowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., Ney, J. P., & van der Goes, D. N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. PAIN , 156 (4). https://journals.lww.com/pain/Fulltext/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx Wexler, R. S. (2022). Protocol for mindfulness-oriented recovery enhancement (MORE) in the management of lumbosacral radiculopathy/radiculitis symptoms: A randomized controlled trial. Contemporary Clinical Trials Communications . Wexler, R. S., Fox, D. J., ZuZero, D., Bollen, M., Parikshak, A., Edmond, H., Lemau, J., Montenegro, D., Ramirez, J., Kwin, S., Thompson, A. R., Carlson, H. L., Marshall, L. M., Kern, T., Mist, S. D., Bradley, R., Hanes, D. A., Zwickey, H., & Pickworth, C. K. (2024). Virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) reduces daily pain intensity in patients with lumbosacral radiculopathy: A randomized controlled trial. Pain Reports , 9 (2), e1132. https://doi.org/10.1097/PR9.0000000000001132 Wilson, J. M., Haliwa, I., Lee, J., & Shook, N. J. (2023). The role of dispositional mindfulness in the fear-avoidance model of pain. PLOS ONE , 18 (1), e0280740. https://doi.org/10.1371/journal.pone.0280740 Yong, R. J., Mullins, P. M., & Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States. Pain , 163 (2), e328–e332. https://doi.org/10.1097/j.pain.0000000000002291 Zale, E. L., Lange, K. L., Fields, S. A., & Ditre, J. W. (2013). The relation between pain-related fear and disability: A meta-analysis. The Journal of Pain , 14 (10), 1019–1030. https://doi.org/10.1016/j.jpain.2013.05.005 Zeidan, F., Baumgartner, J. N., & Coghill, R. C. (2019). The neural mechanisms of mindfulness-based pain relief: A functional magnetic resonance imaging-based review and primer. Pain Reports , 4 (4), e759. https://doi.org/10.1097/PR9.0000000000000759 Zeidan, F., Emerson, N. M., Farris, S. R., Ray, J. N., Jung, Y., McHaffie, J. G., & Coghill, R. C. (2015). Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. The Journal of Neuroscience : The Official Journal of the Society for Neuroscience , 35 (46), 15307–15325. PubMed. https://doi.org/10.1523/JNEUROSCI.2542-15.2015 Additional Declarations Competing interest reported. Eric Garland, PhD, LCSW is the Director of UCSD ONEMIND (Optimized Neuroscience-Enhanced Mindfulness Intervention Development). UCSD ONEMIND provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers. Dr. Garland also receives royalties from the sale of books related to MORE. Dr. Garland is also a consultant and licensor to BehaVR, LLC. Cite Share Download PDF Status: Published Journal Publication published 06 Mar, 2026 Read the published version in Mindfulness → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7104279","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493093295,"identity":"7d5ccf29-c839-4741-b77d-437e7788b13a","order_by":0,"name":"Ryan S. Wexler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDADPgYGxgdQtgFxWtgYGJhhSonXwiZBlBbzGcnPHjC22SS2sfc+qy5suxPNwN68TQKfFpkbaeYGjG1pxmw8x81uz2x7ltvAc6wMrxYJiQQzCcZth+XYJNLYbvO2Hc5tkMgxI6Al/RtQy38eNvlnbMVgLfJvCGnJAdlyAGgLGxszxBYeAlp43pRJJP5LBvoljVma59zh3DaetGILvFrY07dJfDhjl9jPfozxM0/Z4dx+9sMbb+DTwiCQwMCQgCzAhlc5CPAfIKhkFIyCUTAKRjoAAMa/Pf0oAMjuAAAAAElFTkSuQmCC","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ryan","middleName":"S.","lastName":"Wexler","suffix":""},{"id":493093296,"identity":"ab0497ab-036f-4eaf-b0cb-3ba852b5d2d5","order_by":1,"name":"Wade Balsamo","email":"","orcid":"","institution":"Himalayan Institute","correspondingAuthor":false,"prefix":"","firstName":"Wade","middleName":"","lastName":"Balsamo","suffix":""},{"id":493093297,"identity":"03c5c7fb-cd0e-44d0-b382-fe4415f18b20","order_by":2,"name":"Devon J. Fox","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Devon","middleName":"J.","lastName":"Fox","suffix":""},{"id":493093298,"identity":"a3cc7514-f58a-43f6-8d50-3e67a21e7a9d","order_by":3,"name":"Danielle ZuZero","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"ZuZero","suffix":""},{"id":493093299,"identity":"d75ea95d-23c2-4477-863f-8b42b59d3177","order_by":4,"name":"Anand Parikshak","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Anand","middleName":"","lastName":"Parikshak","suffix":""},{"id":493093300,"identity":"19466ec6-8992-4d37-ad8e-d5e3d5fc933f","order_by":5,"name":"Sophia Kwin","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"","lastName":"Kwin","suffix":""},{"id":493093301,"identity":"f647a780-6d21-412f-aa73-63bb43986372","order_by":6,"name":"Jillian Ramirez","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jillian","middleName":"","lastName":"Ramirez","suffix":""},{"id":493093302,"identity":"86ea7926-0ce6-4692-84c6-7c15c8fbafdb","order_by":7,"name":"Austin R. Thompson","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Austin","middleName":"R.","lastName":"Thompson","suffix":""},{"id":493093303,"identity":"a2753b0a-827a-4715-9ea3-bed460fbfcd5","order_by":8,"name":"Hans L. Carlson","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Hans","middleName":"L.","lastName":"Carlson","suffix":""},{"id":493093304,"identity":"243e8b84-14ab-4f33-a21b-b6410e307844","order_by":9,"name":"Thomas Kern","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Kern","suffix":""},{"id":493093305,"identity":"6174afce-8f19-4d32-8ef7-e281a80c20d8","order_by":10,"name":"Scott D. Mist","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"D.","lastName":"Mist","suffix":""},{"id":493093306,"identity":"658ed4b1-d879-4243-9a93-516b1d9aee3a","order_by":11,"name":"Ryan Bradley","email":"","orcid":"","institution":"University of California, San Diego","correspondingAuthor":false,"prefix":"","firstName":"Ryan","middleName":"","lastName":"Bradley","suffix":""},{"id":493093307,"identity":"1e8a8f24-fd32-466c-be20-be6765101933","order_by":12,"name":"Heather Zwickey","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Zwickey","suffix":""},{"id":493093308,"identity":"fb841274-1884-48f1-9c2f-4bc63aa48fe2","order_by":13,"name":"Courtney K. Pickworth","email":"","orcid":"","institution":"National University of Natural Medicine","correspondingAuthor":false,"prefix":"","firstName":"Courtney","middleName":"K.","lastName":"Pickworth","suffix":""},{"id":493093310,"identity":"ef8ae855-5ca1-40b4-b4d7-afc95298ecd4","order_by":14,"name":"Eric L. Garland","email":"","orcid":"","institution":"University of California, San Diego","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"L.","lastName":"Garland","suffix":""}],"badges":[],"createdAt":"2025-07-11 19:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7104279/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7104279/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12671-026-02782-1","type":"published","date":"2026-03-06T15:59:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88099072,"identity":"884bc8a7-7bfa-455c-bae6-c16f985d5afb","added_by":"auto","created_at":"2025-08-01 11:13:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29237,"visible":true,"origin":"","legend":"\u003cp\u003eStages of mindfulness skill development that emerged inductively from participant narratives. The PURER (Phenomenology, Utilization, Reframing, Education, Reinforcement) framework appeared to support progression through these non-linear stages.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7104279/v1/c85e669b3071d8120b5b5926.png"},{"id":104250752,"identity":"863a3bbb-2e32-4e8a-887f-3efa996d44b9","added_by":"auto","created_at":"2026-03-09 16:07:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1102439,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7104279/v1/c801f8ab-8be5-44bd-a7e8-cfaadbfae9fe.pdf"}],"financialInterests":"Competing interest reported. Eric Garland, PhD, LCSW is the Director of UCSD ONEMIND (Optimized Neuroscience-Enhanced Mindfulness Intervention Development). UCSD ONEMIND provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers. Dr. Garland also receives royalties from the sale of books related to MORE. Dr. Garland is also a consultant and licensor to BehaVR, LLC.","formattedTitle":"\"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","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eChronic pain is a pervasive health issue affecting approximately 20% of adults in the United States (Yong et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Among chronic pain conditions, lumbosacral radicular pain (LRP), commonly known as sciatica or spine related leg-pain, presents a particularly challenging clinical picture (Mahmutović et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Schmid et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). LRP is characterized by pain, sensory loss, and motor/reflex abnormalities most commonly resulting from compression of the L4-S1 nerve roots (Tarulli \u0026amp; Raynor, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This condition not only causes significant physical discomfort but also contributes to decreased quality of life (Konstantinou et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTraditional approaches to managing LRP often involve pharmacological interventions, including opioid medications, which carry risks of dependence and abuse (Vowles et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Considering these challenges, there is a growing interest in non-pharmacological, mind-body interventions for chronic pain management. Mindfulness-based interventions (MBIs) have shown promise in this regard, demonstrating efficacy in reducing pain severity and improving pain-related functioning (Hilton et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).While previous research has demonstrated the effectiveness of MBIs for chronic pain conditions (Hilton et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), less is known about the psychological mechanisms and therapeutic progression through which participants develop adaptive relationships with pain.\u003c/p\u003e\u003cp\u003eMindfulness-Oriented Recovery Enhancement (MORE) represents a novel approach within the field of MBIs (Garland, Hanley, et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Garland, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Parisi et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). MORE integrates mindfulness training with principles from cognitive-behavioral therapy and positive psychology to specifically target the dysregulation of reward processing and attentional bias towards pain-related cues that often characterize chronic pain conditions (Garland \u0026amp; Howard, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The program aims to enhance participants' ability to notice and savor natural rewards while simultaneously developing a more adaptive relationship with pain sensations. Prior full-scale randomized controlled trials (RCTs) have demonstrated MORE\u0026rsquo;s efficacy for treating heterogeneous forms of chronic pain and reducing opioid use; in the largest such trial, MORE reduced opioid misuse by 45%, nearly tripling the effect of standard group therapy, while significantly decreasing pain severity and pain-related functional interference through a 9-month follow-up (Garland, Hanley, et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A more recent early-stage randomized controlled trial examined MORE's efficacy specifically for LRP symptoms, and while quantitative outcomes demonstrated MORE's positive impact on pain intensity, understanding if and how participants\u0026rsquo; relationship with pain changes throughout the intervention \u0026ndash; requires qualitative investigation (Wexler, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA key component of MORE is its structured model of therapeutic processing, known as PURER: Phenomenology, Utilization, Reframing, Education/Expectancy, Reinforcement (Garland, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In each session, a trained clinician uses the PURER approach to process the in-session mindfulness practices via inquiry into phenomenology of the meditative experience; utilization of in-session meditative experiences to facilitate generalization of learning to coping with symptoms outside of the session; reframing challenges that arise during meditation as the practice of mindfulness; education about meditative phenomena and building positive therapeutic expectancy; and positive reinforcement for engaging in mindfulness practice attempts (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). PURER draws from behavioral change theory principles of selective reinforcement and successive approximation to shape participant responses to meditation practice towards the successful application of mindfulness toward pain relief and other therapeutic goals (e.g., emotion regulation, reduction of opioid use). This model guides participants through a process of exploring their pain experiences, reappraising their relationship to pain, and reinforcing adaptive coping strategies. However, despite the growing body of research supporting the efficacy of MORE for various chronic pain conditions, its specific impact on LRP and the psychological mechanisms through which it influences pain perception and pain management remain underexplored. Understanding the therapeutic progression fostered by the PURER approach is crucial for optimizing intervention delivery and supporting participants through common challenges.\u003c/p\u003e\u003cp\u003ePrevious research suggests that mindfulness can reduce pain-related suffering (McCracken et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2007\u003c/span\u003e); however the path to therapeutic benefit may not be linear, as research indicates that initial attempts at mindfulness practice may present challenges in implementation and understanding. In addition, prior work has revealed multiple complex interactions between mindfulness, pain catastrophizing, pain intensity, and fear-avoidance patterns. Sch\u0026uuml;tze et al. previously showed that mindfulness acts as a moderator of the relationship between pain catastrophizing and fear-avoidance and that mindfulness also moderates the relationship between pain catastrophizing and pain intensity (Sch\u0026uuml;tze et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Wilson et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study analyzed session recordings from participants in the MORE arm of a randomized controlled trial for LRP patients. Our analysis focused on how participants described their experiences with mindfulness practice, pain perception, and the application of MORE skills in daily life. This study sought to address critical gaps in our understanding of how MBIs facilitate therapeutic change in chronic pain conditions. We aimed to identify the process by which MORE encourages a shift in pain perception that is often reported among individuals suffering with pain-related disability due to LRP. In addition, we hypothesized the presence of distinct stages in participants' progression through phenomenological inquiry that may elucidate the mechanisms through which mindfulness influences pain perceptions. Understanding how participants navigate and develop an adaptive relationship with pain could inform clinical practice and theoretical models of mindfulness-based pain management.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Ethical Considerations and Data Management\u003c/h2\u003e\u003cp\u003eThe clinical trial in which this qualitative data was collected was approved by the Institutional Review Board of the National University of Naturopathic Medicine (IRB #: KP112720). To protect participant confidentiality, identifying information was removed from transcripts and participants were assigned pseudonyms. Audio recordings and anonymized transcripts were stored on encrypted servers accessible only to the research team.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study Design and Sample\u003c/h2\u003e\u003cp\u003eThis qualitative investigation analyzed recorded sessions from 37 participants receiving MORE as part of a randomized controlled trial for LRP (Wexler, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The parent study recruited participants aged 18\u0026ndash;65 years who either had a physician-confirmed LRP diagnosis or reported chronic LRP symptoms with the presence of neuropathic pain on screening (painDETECT scores\u0026thinsp;\u0026gt;\u0026thinsp;15). Exclusion criteria included recent epidural steroid injections (\u0026lt;\u0026thinsp;3 months), inability to complete 20 unassisted gait cycles, recent surgical interventions for back pain or radicular pain (\u0026lt;\u0026thinsp;6 months), an existing mindfulness practice, concurrent cancer diagnosis, and unmanaged psychotic disorders.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Collection and Preparation\u003c/h2\u003e\u003cp\u003eWe analyzed 30 audio recordings from the 8-week MORE intervention, each consisting of 2-hour group sessions following the manualized MORE for Pain protocol (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Garland, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wexler, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)). All MORE sessions followed a similar structure which included: mindfulness of pain practice, practice debriefing, daily homework review, new psychoeducational content, experiential exercises, and a closing discussion. Recordings were transcribed verbatim using Whisper speech recognition software, with researchers manually verifying transcript accuracy. To reduce potential bias in analysis of participants\u0026rsquo; progress through the program, transcripts stripped of session numbers and randomized before qualitative coding began.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMORE Session Topics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhat is Pain and Why Can Mindfulness Help?\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutomaticity in Chronic Pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMindful Reappraisal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMindful Savoring\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelationship between Pain and Unhealthy Coping Mechanisms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisrupting the Link between Stress and Pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain and Thought Suppression, Mindfulness to Meaning and Interdependence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSession 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReview and Discussion of Maintaining a Mindfulness Practice\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Qualitative Coding\u003c/h2\u003e\u003cp\u003eWe employed thematic analysis throughout the qualitative coding process. At weekly meetings, RSW and WB discussed transcript excerpts allowing codes to arise from the data. A preliminary codebook was developed using terms from the MORE manual and MBI literature such as \u0026ldquo;chronic pain\u0026rdquo;, \u0026ldquo;guided inquiry\u0026rdquo;, \u0026ldquo;mindful reappraisal\u0026rdquo;, and \u0026ldquo;attention regulation\u0026rdquo;. This initial codebook was applied to a sample of seven transcripts which were coded independently and in-duplicate. After each transcript was coded, consensus meetings were held to refine the codebook and code definitions. Coding was completed using the Delve software (\u003cem\u003eDelve, a Cloud-Based CAQDAS Tool for Coding in Qualitative Research\u003c/em\u003e, 2025).\u003c/p\u003e\u003cp\u003eTo maintain methodological rigor, we implemented multiple validation strategies. Consensus meetings allowed for discussions about divergent interpretations of the data. In addition, we actively sought and analyzed negative cases - instances where participant experiences deviated from emerging patterns - to ensure our analysis captured the full range of participant experiences. Coding memos were used to document analytical decisions and emerging interpretations. Data triangulation included comparison with quantitative outcomes from the parent study and consultation with MORE therapists to verify interpretations of participant-therapist interactions (Carter et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOnce a refined version of the codebook had been developed and all transcripts were coded, codes were organized into themes, with supporting quotes cataloged for each theme. The research team then reviewed these themes against both the coded excerpts and complete dataset to ensure comprehensive representation of participant experiences. The resulting analysis provides a detailed account of participant experiences and therapeutic progression patterns. While our analysis was informed by prior research on mindfulness and chronic pain, our coding process remained inductive and data-driven. As themes coalesced, we identified consistent patterns in how participants described the development of mindfulness skills, which later informed our understanding of therapeutic progression.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 PURER Framework of Therapeutic Processing\u003c/h2\u003e\u003cp\u003eThe PURER model (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) provides a framework for MORE therapists to engage participants in guided inquiry about their mindfulness practice (Garland, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This systematic model of questioning was used after each mindfulness practice during weekly sessions to facilitate participants\u0026rsquo; exploration and understanding of their pain experiences. The therapist\u0026rsquo;s role in this process is to support attention development through phenomenological inquiry about mindfulness experiences, validate participants\u0026rsquo; challenges while reinforcing progress, educate participants about normal mind-wandering, and encourage participants to continue practicing despite difficulties. In our analysis, we used PURER to provide structure to the analytic approach of in-session qualitative data.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePURER Steps and Definitions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePURER Step\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePhenomenology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTherapists used open-ended but directive questions to elicit detailed descriptions of participants' moment-to-moment experiences during mindfulness practices, with a focus on eliciting positive or therapeutic experiences. Participants where queried about the temporal sequence and unfolding of their meditative experiences. These inquiries focused on physical sensations, emotional responses, and cognitive processes (e.g., \"What did you notice about your experience?\" \"Where did your attention go?\"). This phenomenological data formed the foundation for subsequent components of the framework, particularly a starting point in discussion that could be followed by other participants.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUtilization\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTherapists actively incorporated participants' reported experiences into teaching key concepts and skills for coping in everyday life. Participants were asked how they could use what the learned from the mindfulness practice session to address their symptoms in everyday life outside of the session.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReframing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReframing was facilitated through guided discussion of alternative interpretations of pain experiences and used as examples of the lesson being taught within the MORE session. Therapists helped participants examine their automatic pain-related thoughts and develop more adaptive perspectives. Therapists also reframed the inevitable challenges that arise during meditation as the practice of mindfulness.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation / Expectancy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducational elements were systematically integrated to help participants understand the relationship between attention, pain perception, and emotional responses. This included explanation of relevant neurobiological mechanisms of pain and the psychological principles underlying mindfulness practices. Importantly, therapists aim to build an expectation of therapeutic benefit in this step.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReinforcement\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTherapists consistently acknowledged and reinforced participants' efforts to engage with mindfulness practices and their emerging insights about pain management. This positive reinforcement aimed to strengthen pain coping strategies and maintain engagement with the intervention.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e This framework of in-session interviewing not only provided the structure for data collection and an intimate lens through which to examine participant experiences and progression through the intervention, but as session recordings were evaluated, the implementation of PURER emerged as an integral part of the skill development supporting therapeutic change.\u003c/p\u003e\u003cp\u003e Before describing participants\u0026rsquo; therapeutic progression, it is important to briefly introduce the specific mindfulness practice taught in MORE. A key practice in MORE is the \u0026ldquo;mindfulness of pain\u0026rdquo; technique, which goes beyond general mindful breathing. Participants are taught two complementary attentional strategies: \u0026ldquo;zooming out\u0026rdquo; and \u0026ldquo;zooming in.\u0026rdquo; Zooming out involves redirecting attention away from the pain (often toward the breath or body as a whole) to reduce emotional reactivity or distress. In contrast, zooming in guides participants to attend directly to the pain itself, observing its sensory features such as intensity, location, texture, and boundaries. Participants learn to decompose pain into component sensations (e.g., heat, tingling, pressure) and to explore surrounding areas for neutral or pleasant contrast. This practice facilitates a shift from affective interpretation to direct sensory awareness, supporting reappraisal and reducing suffering. Both techniques are introduced within the MORE program as therapeutic tools, helping participants build a more adaptive relationship to pain.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe final sample was predominantly white (81%) and female (70%), with a mean age of 48.59 years and a mean condition duration of 13.72 years. At baseline, participants had an Oswestry Disability Index score of 19.70 and a pain visual analogue scale score of 5.14 (0\u0026thinsp;=\u0026thinsp;no pain; 10\u0026thinsp;=\u0026thinsp;most pain); \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eWexler et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)) All demographic characteristics can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics at baseline presented as mean (SD) or n (%) from Wexler et al. (Wexler et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (70%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnglo-American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic/Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Eastern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 1 race\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe qualitative analysis found four distinct stages and one common barrier of mindfulness skill development characterized by participants' progression through the MORE program: 1) attention dysregulation, 2a) competency with attention regulation, 2b) barrier \u0026ndash; experiential avoidance, 3) metacognitive awareness, and 4) pain reappraisal. In addition, we found that the stepwise nature of PURER facilitated progression through these stages during the MORE program (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The following quotes describe progression through these stages. It is important to note that, just as with any new skill, learning mindfulness does not always occur in a linear fashion; we observed many participants still experiencing challenges in later weeks of the MORE program.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Stage 1: Attention Dysregulation\u003c/h2\u003e\u003cp\u003eEarly sessions in the MORE program focus on building basic mindfulness skills. Here, participants expressed their initial challenges, which generally appear as difficulty maintaining attention \u0026ndash; a phenomenon commonly seen in chronic pain patients (Alcon et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Battison et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ibrahim \u0026amp; Hefny, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Some participants expressed doubt about their capacity to successfully engage in mindfulness practice:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"...maybe I had doubt early on because I have so many attention issues, [I doubted] if I would be able to do this practice well.\"\u003c/em\u003e [Cohort 1, Session 5]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants consistently reported difficulties with basic attention regulation in early sessions, particularly around maintaining focus during meditation practices.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"The most difficult part... I mean, I feel like it's this every time, is just sort of staying, like keeping my mind on track with it, just not getting distracted by other things\" [Cohort 3, Session 3]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMORE therapists deal with this common complaint by reframing the attentional lapse as the practice of mindfulness. This encourages participants to continue working towards the development of mindfulness as a skill by providing reinforcement that they are on the right track.\u003c/p\u003e\u003cp\u003ePhysical discomfort also affected participants\u0026rsquo; ability to maintain attention. In particular, participants expressed that their pain made it challenging to be still during meditation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"...if I'm still, my body, the pain in the hips will flare up. So I'll have to move. And it's like a butterfly effect with my brain. Once I have that pain and I move, my focus is lost.\"\u003c/em\u003e [Cohort 3, Session 2]\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI went to the part that was painful. And I was okay there, but then I think it's, I don't know. I had to keep moving. I can\u0026rsquo;t, I can't lay still\u003c/em\u003e.\" [Cohort 1, Session 4]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn this first stage, participants demonstrated characteristic patterns of attention dysregulation that manifested as pain vigilance, or an inability to easily move their attention away from their pain experiences (Badiei et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2.a Stage 2: Competency with Attention Regulation\u003c/h2\u003e\u003cp\u003e As participants practiced breath awareness and mindfulness skills emerged, they noted qualitative shifts in their attention regulation abilities over time. The development of these skills was evidenced through multiple participant narratives that demonstrated increasingly sophisticated attentional capabilities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThere's less fight going on internally as far as the intention goes than it was four weeks ago. It's almost like a switch now. Whereas before, it was really back and forth, back and forth. And now it's operating much smoother\u003c/em\u003e.\" [Cohort 1, Session 5]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLooking back, some participants expressed a critical shift from avoidance-based coping strategies to an approach-oriented engagement with pain sensations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eI think for me [before the program], I would just do things to not feel the pain, ya know? I knew it was there all the time, but instead of focusing on it, this helped me go in, relieve it a little more and then let it go. Even though I still have it, but it\u0026rsquo;s not as bad\u003c/em\u003e.\" [Cohort 1, Session 8]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOver time, participants demonstrated general attention regulation across multiple domains:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"When I first started\u0026hellip; I was really scattered, and I had a hard time staying in tune with it. And this time, well, I really noticed the whole time, it's my ability to like jump in and get into that state and stay in that state better than before.\"\u003c/em\u003e [Cohort 1, Session 8]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor example, this participant developed reduced mind wandering, suggesting improved focus; enhanced ability to \u0026ldquo;jump in\u0026rdquo; and enter meditative states, indicating improved attentional flexibility; and increased capacity to \u0026ldquo;stay in that state\u0026rdquo; and maintain attention over time, reflecting improved attention regulation. While these emerging skills marked important progress, they also introduced a new challenge: some participants used their enhanced attention to avoid pain rather than engage with it.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2.b Experiential Avoidance\u003c/h2\u003e\u003cp\u003e Once participants had developed an initial ability to regulate their attention and a basic competency with mindfulness skills, a tendency emerged in some participants to use these skills for cognitive avoidance, avoiding or escaping distressing thoughts or experiences, rather than engagement with pain experiences.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It was hard for me to get past the pain that I have. I kept trying to circle back and try to make it go away, but I was having a really hard time\u0026hellip; I'm trying to not think about it. Just think about the breathing and staying with the breathing.\"\u003c/em\u003e [Cohort 1, Session 7]\u003c/p\u003e\u003cp\u003eIn some cases, this distancing approach could be adaptive to provide individuals the time and attention required to approach their discomfort in a therapeutic manner (Folkman \u0026amp; Moskowitz, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Sagui-Henson, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e As participants gained basic attention control, many initially employed these skills to avoid pain experiences rather than engage with them mindfully, which manifested as an experiential avoidance: \u0026ldquo;the attempt to avoid internal experiences (e.g. thoughts, feelings, physical sensations) that are experienced as negative (Mohr, Matthew, 2025).\u0026rdquo; This psychological resistance in fear of the pain experience revealed a complex interplay between attention regulation and pain processing, which manifested as a barrier within the program.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eSo I'm trying to just listen to you and ignore [the pain]... Ignoring the pain instead of going into the pain. It makes it hurt more\u0026hellip;When I ignore the pain, it makes it hurt less\u003c/em\u003e.\" [Cohort 1, Session 6]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome participants described strong psychological resistance to pain exposure:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\" I'm just kind of agitated, it's like my mind is in an agitated state when I'm just laying there. And so part of me feels like, I was dropping in [to the meditation], but I have a lot on my mind. And I notice myself not wanting to do it\u0026hellip; feeling very much wanting to distract myself.\" [Cohort 2, Session 3]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOthers noted how when they pay attention to their pain after being attentive to something else, that\u0026rsquo;s when the pain hurts more.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Now that we're talking about it again though my leg will start firing. It's just when I think about it or talk about it too much\u0026hellip;I think it's something I made up but sometimes it will hurt more.\"\u003c/em\u003e [Cohort 2, Session 5]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther participants embraced the ability to use mindfulness to re-orient attention away from pain:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"It [mindfulness] becomes like a superpower... to fly you somewhere else away from your sorrows and away from the pain\" [Cohort 1, Session 7]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese avoidant tendencies led to a common misunderstanding of the therapeutic practice of mindfulness as a process of escape from pain rather than reprocessing and reappraisal of pain sensations, which highlights the importance of skilled guidance and questioning through early stages of mindfulness-based pain management and suggests the need for careful scaffolding of attention regulation skills that work through these challenges.\u003c/p\u003e\u003cp\u003eCollectively, these narratives document a developmental progression in attention regulation characterized by reduced mind wandering, increased volitional control, enhanced metacognitive awareness, and greater efficiency in attentional processes. This stage represents a critical transition point where basic attentional competencies are established, creating the foundation for the more advanced metacognitive skills to emerge.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Stage 3: Metacognitive Awareness\u003c/h2\u003e\u003cp\u003e When participants engaged in continued practice and guidance after mindfulness sessions, they began to display a more nuanced and adaptive capacity to process their pain perceptions by shifting from affective to sensory processing of pain sensations. Through metacognitive awareness of avoidant tendencies, participants were able to begin engaging in healthy forms of pain reappraisal \u0026ndash; coming to view pain as an innocuous sensation \u0026ndash; and some participants even reported joy in reconnecting with physical sensations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003e[It was] quite enjoyable to be able to just kind of soak in and just kind of feel or experience what my body's experiencing because I've really kind of been detached and, more trying to make it go away and not really focusing on feeling it and trying to figure out where it's at. So it was good to be able to just recognize what my body's doing\u003c/em\u003e.\" [Cohort 2, Session 4]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants also seemed to overcome avoidant tendencies:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"I think like the times when I've noticed I can relax around it, it helps with the pain. Because then I get to notice it's shifting. I'm not bracing against it or like trying to avoid it.\u003c/em\u003e\" [Cohort 2, Session 1]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe therapeutic benefit of metacognitive awareness led to clear shifts in participants' relationship with pain and improved physical function. A key shift involved participants developing the ability to observe their own mental processes and the impact of these processes on physical sensations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Stage 4: Pain Reappraisal\u003c/h2\u003e\u003cp\u003eAs the metacognitive process of looking at the current appraisal of experience can be utilized to re-appraise the experience of pain, participants begin reinterpreting the signals and adapting their relationship with pain.\u003c/p\u003e\u003cp\u003eWhen participants were able to bring mindful awareness to areas of their body with pain through the \u0026ldquo;mindfulness of pain\u0026rdquo; technique taught in MORE enabled them to shift from affective to sensory processing of the pain experience (Garland, Roberts, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and they expressed a shift in their pain experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The more I focused on the breath at that specific point it just seemed like the intensity of the pain decreased into a cool feeling... to where I could kind of calm things down by utilizing the breath.\" [Cohort 4, Session 3]\u003c/p\u003e\u003cp\u003e\"When I went into the pain part of it, it was very jagged and sharp and hot and red... as I breathed more into it, it got less sharp, more of a dull\" [Cohort 1, Session 7]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe observed that some participants used reappraisal to change their relationship to pain entirely and to distinguish their identity from that of their pain experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I have to redefine my definition of pain... that's kind of what I've been set out to do is to redefine my definition of pain and not let it define me and control me and, you know, keep me just useless.\" [Cohort 1, Session 6]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants reported fundamental changes in how they experienced and related to pain:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"It feels like a sense of freedom really, you know, before you feel almost like you are getting a life sentence, like it's not going to end. Yeah, it's really, I feel a little bit like I have a new lease on life, endless of a thought of a life sentence, you know, which is really freeing, which is awesome. And I'm ready to like mentally I'm ready to take off and go running not quite physically though. So like my new lease on life is pushing me through a little bit more for sure, but then maybe at the same time pushing me a little too far at times.\" [Cohort 1, Session 8]\u003c/p\u003e\u003cp\u003e\"[I\u0026rsquo;m] noticing the way that I'm noticing pain... I feel like my relationship to it is changing. Which is great... I noticed that like today, I was walking. And, I don't remember the last time I walked and like, didn't immediately notice pain. I walked out of my house. And, and I think I had gone like a block and a half. And I was like, oh my gosh, like I don't, I'm not experiencing the same kind of pain.\" [Cohort 2, Session 3]f\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.5 The PURER Framework Facilitates Skill Development in Metacognitive Awareness\u003c/h2\u003e\u003cp\u003eWe observed that skillful and systematic implementation of MORE\u0026rsquo;s guided inquiry process, PURER, supported participants in developing an adaptive relationship to their pain. Rather than simply teaching mindfulness techniques, therapists used PURER to help participants navigate challenges and develop increasingly nuanced relationships with pain experiences. In early stages, where participants struggled with basic attention regulation, therapists asked participants to describe their phenomenology, or moment-to-moment experience, to help participants investigate their meditation. Once participants had discussed what occurred for them during the practice session, therapists could use the participant\u0026rsquo;s experience as an example of an important concept being taught. This example, from the first session of the program, describes a participant who was prompted to report novel insights about their anticipations of the pain experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTherapist: \u0026ldquo;\u003cem\u003eI was wondering if maybe you could zoom into a particular part of the meditation when that was happening and tell me how that happened with you and your mind and your breath.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant: \"\u003cem\u003eEvery part of the body that we went to, my body, like, I felt more pain... it wasn't like constant, and it wasn't like... excruciating. it was just like, \u0026lsquo;Oh, you're noticing me and here I am\u0026rsquo;... I noticed like tension right here as you were approaching that... and I was like, that's anticipation... my brain is already deciding that it's kind of hurt before I even get there\u003c/em\u003e. \u003cem\u003eSo I actually tried to relax right here because I felt myself doing that. And I feel like that actually helped.\"\u003c/em\u003e [Cohort 2, Session 1]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e As participants began showing capacity for metacognitive awareness, therapists used phenomenological inquiry to deepen this emerging skill. The therapist reinforced this metacognitive observation while helping utilize it for pain management.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTherapist: \u003cem\u003e\u0026ldquo;What did you enjoy about today's practice?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant: \u003cem\u003e\u0026ldquo;I'm really relaxed. A lot less pain.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTherapist: \u003cem\u003e\u0026ldquo;Good, that's fantastic. When did that start for you in the meditation, [participant name]?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant: \u003cem\u003e\u0026ldquo;Um, I went deep in, came back out, and went deep in. Each time it was a little less.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTherapist: \u003cem\u003e\u0026ldquo;So you found that every time you went back to observe the pain, there was a little bit less there to notice?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant: \u003cem\u003e\u0026ldquo;Mmhm. Yeah. It got softer and softer. Not as deep.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTherapist: \u003cem\u003e\u0026ldquo;That's fantastic. I want to also take some time today, as we are debriefing that experience to focus or reflect on how things have changed over the course of these 8 weeks, 9 weeks now. How does that compare to some of the earlier experiences you had in the program? Do you find that the pain went away quicker? Or did it linger about as long as it used to but you were just more aware of it?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant: \u0026ldquo;\u003cem\u003eI think for me, I would just do things to not feel the pain, ya know? I knew it was there all the time, but instead of focusing on it, this helped me go in, relieve it a little more and then let it go. Even though I still have it, but its not as bad.\u0026rdquo;\u003c/em\u003e [Cohort 1, Session 8]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn general, it appeared that the value of PURER is engrained in how its components worked together to support mindfulness skill development. As participants developed basic attention skills, but showed avoidance tendencies, therapists used phenomenological inquiry to help participants recognize and investigate their avoidance. Rather than criticizing avoidance, therapists used reframing and education to help participants understand its limitations while reinforcing their growing skillset.\u003c/p\u003e\u003cp\u003e The systematic nature of PURER helped ensure key therapeutic elements were consistently present, while its flexibility allowed adaptation to participants' current stage and specific challenges. The framework particularly excelled at helping participants move from avoidance to engagement through careful phenomenological inquiry, strategic reframing, and consistent reinforcement of pain education in the MORE program. This structured and responsive guidance appears crucial for realizing therapeutic benefits from mindfulness-based pain management programs such as MORE.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eBy qualitatively analyzing audio recordings of MORE sessions, this study offers a unique perspective on the lived experiences of individuals with LRP as they begin a new mindfulness practice. This approach allowed us to capture the nuances of participants' evolving relationship with pain in real-time, providing valuable insights into the therapeutic process facilitated by MORE. These findings highlight a systematic progression in how participants develop adaptive relationships with pain through mindfulness practice. An important finding in this work was that the process of mindfulness-skill building was not unidirectional. Participants appeared to move between stages of skill development from week-to-week and even from meditation-to-meditation within a single weekly session. Participants\u0026rsquo; pain experiences in meditation appear to lie along a spectrum on which skill development occurs over time, but challenging experiences, such as difficulty with attention regulation, can continue to occur after weeks of practice. Our findings extend beyond previous research by illuminating both the challenges and transformative processes that can occur during mindfulness-based pain management interventions.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Key Findings and Theoretical Implications\u003c/h2\u003e\u003cp\u003eAlthough the stages are presented linearly for clarity, they reflect themes that arose inductively through qualitative coding. Participants often moved fluidly between these phases, and our analytic structure was developed to reflect the complex, nonlinear nature of their therapeutic progression.\u003c/p\u003e\u003cp\u003eOur findings reveal an important paradox regarding the relationship between attention regulation strategies and functional outcomes in early mindfulness skill development. While participants successfully developed basic attention regulation abilities, they often deployed these skills for experiential avoidance rather than engagement with the experience of pain. This pattern aligns with Hayes' theory of experiential avoidance (Hayes et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Hayes-Skelton \u0026amp; Eustis, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e4.1.1 The Dichotomy of Pain and Disability\u003c/h2\u003e\u003cp\u003eOur findings also highlight a critical observation from the parent clinical trial: while MORE produced a significant reduction in pain intensity, these improvements did not translate to corresponding reductions in disability in this trial (Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The discrepancy between changes in pain intensity reduction and disability presents an important theoretical and clinical question that our qualitative analysis begins to address. We observed participants demonstrating two distinct approaches for attending to pain management through mindfulness: avoidance-based attention regulation and metacognitive awareness-based attention regulation. This dichotomy warrants critical examination within the context of disability outcomes.\u003c/p\u003e\u003cp\u003eParticipants in the avoidance stage successfully employed attention regulation techniques to reduce pain intensity, as evidenced by statements like: \"\u003cem\u003eWhen I ignore the pain, it makes it hurt less\" [Cohort 1, Session 6].\u003c/em\u003e However, this strategy may create a therapeutic \u0026ldquo;ceiling\u0026rdquo; regarding improvements in disability. While momentary pain reduction occurs, participants may remain unable to effectively direct their attention towards the affected areas when necessary, potentially maintaining disability levels despite a reduction in pain (Suso-Ribera et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Zale et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants who developed metacognitive awareness often reported awareness of pain sensations but demonstrated improvements in disability. One participant noted, \u003cem\u003e\"I walked out of my house... and I think I had gone a block and a half. And I was like, \u0026lsquo;Oh my gosh, like I don't, I'm not experiencing the same kind of pain!\u0026rsquo;\"\u003c/em\u003e [Cohort 2, Session 3]. This suggests that while the sensory dimension of pain may persist, one\u0026rsquo;s affective response to pain and one\u0026rsquo;s relationship to the pain sensation is malleable, resulting in reduced disability. In MORE, patients are taught unique mindful breathing and body scan meditations designed to decompose the pain experience into its constituent sensations (e.g., heat, tightness, tingling), as well as to increase awareness of the center, edges, and permeability (versus solidity) of these sensations, and any adjacent or distal pleasant sensations. This practice of cultivating mindful awareness of pain may decrease emotional reactivity to pain and thereby decrease pain intensity. Moreover, this practice may disentangle self-referential processes from pain-related sensory input, an therapeutic approach supported by previous neurobiological research on the relationship between pain and participants\u0026rsquo; sense of self (Riegner et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zeidan et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis observed dichotomy has significant implications for understanding therapeutic mechanisms in MBIs. Although initially learning to orient attention away from pain via mindful breathing may produce analgesic effects (Zeidan et al., 2011, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), the development of pain \u003cem\u003etolerance\u003c/em\u003e through directing meta-awareness towards pain \u0026ndash; rather than experiential avoidance \u0026ndash; may represent a more sustainable pathway to improvements in pain-related disability. Our findings suggest that the ability to direct attention \u003cem\u003etowards\u003c/em\u003e pain when necessary, while maintaining an emotional equilibrium, typically referred to as \u0026ldquo;equanimity\u0026rdquo; within the context of meditation, may be important for achieving reductions in disability. These observations help contextualize the relationship between pain intensity and disability measured in the parent trial (Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) in which pain intensity was reduced while disability was not. However, it should be noted that prior full-scale RCTs have demonstrated that MORE significantly decreases pain-related functional interference, including measures of physical, social, and occupational function (Garland et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Garland, Hanley, et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These conflicting results suggests further investigation into pain-related attention is warranted.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e4.1.2 Phenomenological Inquiry Facilitates Metacognitive Development\u003c/h2\u003e\u003cp\u003eThe PURER framework appeared to be particularly valuable in our study in facilitating the transition from avoidance-based pain management (which may reduce intensity but maintain disability) to metacognitive awareness-based pain management (which may maintain awareness of pain sensations while reducing disability). PURER emerged as crucial in facilitating the transition from avoidance to engagement with the experience of pain. This structured approach to inquiry helped participants move beyond initial avoidance tendencies towards a therapeutic engagement with their pain experience: \"\u003cem\u003enoticing the way that I'm noticing pain... I feel like my relationship to it is changing\u003c/em\u003e\" [Cohort 2 Session 3]. This transformation suggests that therapist guidance through the PURER framework may be essential for realizing therapeutic benefits from MORE. In addition, the valuable role of the therapist highlights the importance of maintaining fidelity to the MORE program when delivering the intervention (Hanley et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinally, participants developed an increasing metacognitive awareness of their experience of pain. The progression from basic attention regulation to complex reappraisal is evident in multiple participants\u0026rsquo; narratives. This development of metacognitive skills appears to be a key mechanism in transforming participants' relationship with pain and is taught to MORE participants using the skill of mindful reappraisal of pain.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Clinical Implications\u003c/h2\u003e\u003cp\u003eClinicians should anticipate that patients with LRP may initially use mindfulness skills for experiential avoidance of their pain experience. The data suggests that acknowledging and working skillfully with avoidance, rather than treating it as failure, may be crucial for therapeutic progress. Early identification of avoidance patterns can help therapists guide participants towards greater engagement with their pain experience.\u003c/p\u003e\u003cp\u003eOur findings also highlight the importance of carefully scaffolding the transition from basic attention training to mindful exposure to pain. The challenges documented in our analysis, such as \u003cem\u003e\"I just had a hard time getting settled... I couldn't get comfortable\"\u003c/em\u003e [Cohort 1 Session 4], suggest the need for a gradual progression and robust support during this phase.\u003c/p\u003e\u003cp\u003eFinally, the success of the PURER model in facilitating change suggests the importance of maintaining fidelity to this structured approach to therapeutic processing. Therapists should be trained to skillfully implement each component of PURER, using them systematically to support participants\u0026rsquo; progress through MORE. As facilitators learn to deliver MORE and apply the PURER model, the MORE Fidelity Measure should be used to ensure therapist competence and adherence to the model (Hanley \u0026amp; Garland, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Interpretation of Findings in Relation to Existing Literature\u003c/h2\u003e\u003cp\u003eOur results align with and extend previous research on the use of MBIs for chronic pain. The shifts in pain perception reported by our participants, characterized by increased metacognitive awareness, reappraisal of pain sensations, and a move towards acceptance, support the notion that mindfulness practices can alter the cognitive and affective dimensions of pain, even when sensory aspects persist (Kabat-Zinn, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1982\u003c/span\u003e). In addition, the present results provide a detailed account of how metacognitive awareness develops over time and its specific application to LRP symptoms. Participants were able to observe their pain with greater detachment, a key psychological mechanism of mindfulness interventions called decentering (Hanley et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hick \u0026amp; Chan, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe process of mindful reappraisal of pain sensations (Garland, Roberts, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) observed in our study extends beyond simple distraction techniques often used in pain management programs. Instead, it involves a sophisticated re-evaluation of the pain experience, consistent with previous research (Ashar et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sch\u0026uuml;tze et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). In addition, the observed shift from experiential avoidance to greater acceptance of pain aligns with the psychological flexibility model underlying Acceptance and Commitment Therapy (ACT) for chronic pain (McCracken et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Vowles et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, the pain relieving effects of MORE have been shown to be statistically mediated by reinterpretation of pain as innocuous sensation (Garland et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Garland, Roberts, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), demonstrating that MORE operates through mechanisms other than acceptance through its integration of mindfulness meditation, reappraisal, and savoring practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Strengths, Limitations, and Future Directions\u003c/h2\u003e\u003cp\u003eA key strength and novel aspect of our study is the use of session recordings for qualitative analysis. This approach allowed us to capture the dynamic, moment-to-moment experiences of participants as they engaged with the MORE program, providing a level of detail and immediacy often missing from retrospective interviews or quantitative measures. The analysis of session recordings revealed the nuanced ways in which the PURER model guided participants' exploration and processing of their pain experiences. These findings contribute to our understanding of the specific components of MORE that may drive its therapeutic effects, addressing calls in the literature for greater specificity in understanding the active ingredients of MBIs (Gordon, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Mohr et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Our study also provides insights into the challenges and barriers faced by individuals with LRP in engaging with mindfulness practices. These findings can inform the refinement of MBIs to better address the specific needs of this population, potentially improving adherence and outcomes. Finally, our qualitative findings are corroborated by quantitative data from our previous publications indicating that participants experienced increases in scores on both the Mindful Reappraisal of Pain Sensations scale and the Five Facet Mindfulness Questionnaire - a measure of trait mindfulness (62.79% and 8.41% increases, respectively) (Wexler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile our study provides valuable insights, it has important limitations. First, our analysis focused on session recordings, where the virtual delivery format may have influenced participant experiences and therapist-participant interactions. Future research should examine whether similar progression patterns emerge within in-person settings. Second, this study only examined participant experiences with meditation during the MORE program and did not collect data on how participant mindfulness experiences may have changed after completing the intervention. Finally, while our analysis identified clear progression patterns, individual variations in this progression warrant further investigation. Due to the group design of this study, we were not able to identify specific participants on the audio recordings and track their progression over the course of the program. Rather, we were identifying shifts in an entire cohort\u0026rsquo;s understanding of MORE concepts from week-to-week via longitudinal qualitative analysis (Grossoehme \u0026amp; Lipstein, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe four-stage progression model identified in this study may serve as a foundation for future efforts to track therapeutic progress more efficiently. With recent advances in artificial intelligence, researchers are beginning to explore whether large language models can help analyze qualitative data, such as session transcripts, in a more automated way. Early studies have shown that this approach is feasible (Lennon et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Building on these developments, future research could use clearly defined therapeutic stages, like those described here, to support structured, theory-driven analysis of participant experiences. This could make it easier to refine and improve mindfulness-based interventions, even in small studies.\u003c/p\u003e\u003cp\u003eOur findings suggest several promising directions for future research. The stages of skill development that we identified may be associated with important clinical outcomes, such as kinesiophobia or disability. Future studies might also examine factors that facilitate or impede progression through these stages. Assessing these stages throughout intervention delivery, as is done in iterative user-/human-centered design (Alwashmi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), could allow the development of more personalized teaching and therapy strategies. Studies that aim to build on this work should consider investigating strategies to mitigate the tendency towards experiential-avoidance early in the program and attempt to assess a participant\u0026rsquo;s progression through the various stages of mindfulness skill development in real time.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis qualitative study identified a four-stage progression in mindfulness skill development among individuals with lumbosacral radicular pain: attention dysregulation, competency with attention regulation, metacognitive awareness, and pain reappraisal. These stages provide a framework for understanding common challenges and therapeutic opportunities in mindfulness-based pain interventions. Crucially, the PURER model of guided inquiry facilitated this progression, helping participants move from avoidance toward adaptive engagement with pain. These findings offer a clinically actionable model for tailoring instruction, reinforcing the importance of therapist skill and program fidelity. As nonpharmacologic strategies for chronic pain evolve, incorporating structured, stage-informed guidance into interventions like MORE may improve outcomes for patients with LRP and related conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEric Garland, PhD, LCSW is the Director of UCSD ONEMIND (Optimized Neuroscience-Enhanced Mindfulness Intervention Development). UCSD ONEMIND provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers. Dr. Garland also receives royalties from the sale of books related to MORE. Dr. Garland is also a consultant and licensor to BehaVR, LLC.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eRSW and WB were responsible for drafting the initial version of the manuscript. RSW, DJF, DZ, ART, SK, JR, and CKP were responsible for data collection. RSW, AP, ART, HLC, TK, SDM, RB, DAH, HZ, and CKP were responsible for the design of the parent trial in which the present data were collected. EG provided critical edits on the manuscript consistent with MORE\u0026rsquo;s theoretical framework. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, RSW, upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlcon, C., Krieger, C., \u0026amp; Neal, K. (2025). The Relationship Between Pain Catastrophizing, Kinesiophobia, Central Sensitization and Cognitive Function in Patients with Chronic Low Back Pain. \u003cem\u003eThe Clinical Journal of Pain\u003c/em\u003e. https://doi.org/10.1097/AJP.0000000000001293\u003c/li\u003e\n \u003cli\u003eAlwashmi, M. F., Hawboldt, J., Davis, E., \u0026amp; Fetters, M. D. (2019). The Iterative Convergent Design for Mobile Health Usability Testing: Mixed Methods Approach. \u003cem\u003eJMIR mHealth and uHealth\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(4), e11656. https://doi.org/10.2196/11656\u003c/li\u003e\n \u003cli\u003eAshar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., \u0026amp; Wager, T. D. (2022). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e, \u003cem\u003e79\u003c/em\u003e(1), 1\u0026ndash;12. https://doi.org/10.1001/jamapsychiatry.2021.2669\u003c/li\u003e\n \u003cli\u003eBadiei, F., Brewer, B. W., \u0026amp; Van Raalte, J. L. (2023). Associations of Pain Vigilance and Past and Current Pain with Kinesiophobia after Sport Injury in Current and Former Athletes from Iran and the United States. \u003cem\u003eJournal of Functional Morphology and Kinesiology\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(3), 117. https://doi.org/10.3390/jfmk8030117\u003c/li\u003e\n \u003cli\u003eBattison, E. A. J., Brown, P. C. M., Holley, A. L., \u0026amp; Wilson, A. C. (2023). Associations between Chronic Pain and Attention-Deficit Hyperactivity Disorder (ADHD) in Youth: A Scoping Review. \u003cem\u003eChildren\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 142. https://doi.org/10.3390/children10010142\u003c/li\u003e\n \u003cli\u003eCarter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., \u0026amp; Neville, A. J. (2014). The use of triangulation in qualitative research. \u003cem\u003eOncology Nursing Forum\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(5), 545\u0026ndash;547. https://doi.org/10.1188/14.ONF.545-547\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eDelve, a cloud-based CAQDAS tool for coding in qualitative research\u003c/em\u003e (Version 2086). (2025). [Computer software]. Twenty to Nine LLC. https://delvetool.com/\u003c/li\u003e\n \u003cli\u003eFolkman, S., \u0026amp; Moskowitz, J. T. (2004). Coping: Pitfalls and promise. \u003cem\u003eAnnual Review of Psychology\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e, 745\u0026ndash;774. https://doi.org/10.1146/annurev.psych.55.090902.141456\u003c/li\u003e\n \u003cli\u003eGarland, E. L. (2013). \u003cem\u003eMindfulness Oriented Recovery Enhancement\u003c/em\u003e. NASW Press.\u003c/li\u003e\n \u003cli\u003eGarland, E. L. (2024). \u003cem\u003eMindfulness-oriented recovery enhancement: An evidence-based treatment for chronic pain and opioid use\u003c/em\u003e. The Guilford Press.\u003c/li\u003e\n \u003cli\u003eGarland, E. L., Hanley, A. W., Nakamura, Y., Barrett, J. W., Baker, A. K., Reese, S. E., Riquino, M. R., Froeliger, B., \u0026amp; Donaldson, G. W. (2022). Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care. \u003cem\u003eJAMA Internal Medicine\u003c/em\u003e, \u003cem\u003e182\u003c/em\u003e(4), 407\u0026ndash;417. https://doi.org/10.1001/jamainternmed.2022.0033\u003c/li\u003e\n \u003cli\u003eGarland, E. L., \u0026amp; Howard, M. O. (2013). Mindfulness-Oriented Recovery Enhancement Reduces Pain Attentional Bias in Chronic Pain Patients. \u003cem\u003ePsychotherapy and Psychosomatics\u003c/em\u003e, \u003cem\u003e82\u003c/em\u003e(5), 311\u0026ndash;318. https://doi.org/10.1159/000348868\u003c/li\u003e\n \u003cli\u003eGarland, E. L., Manusov, E. G., Froeliger, B., Kelly, A., Williams, J. M., \u0026amp; Howard, M. O. (2014). Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e82\u003c/em\u003e(3), 448\u0026ndash;459. https://doi.org/10.1037/a0035798\u003c/li\u003e\n \u003cli\u003eGarland, E. L., Nakamura, Y., Bryan, C. J., Hanley, A. W., Parisi, A., Froeliger, B., Marchand, W. R., \u0026amp; Donaldson, G. W. (2024). Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial. \u003cem\u003eThe American Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e181\u003c/em\u003e(2), 125\u0026ndash;134. https://doi.org/10.1176/appi.ajp.20230272\u003c/li\u003e\n \u003cli\u003eGarland, E. L., Roberts, R. L., Hanley, A. W., Zeidan, F., \u0026amp; Keefe, F. J. (2022). The Mindful Reappraisal of Pain Scale (MRPS): Validation of a New Measure of Psychological Mechanisms of Mindfulness-Based Analgesia. \u003cem\u003eMindfulness\u003c/em\u003e. https://doi.org/10.1007/s12671-022-02034-y\u003c/li\u003e\n \u003cli\u003eGordon, W. V. (2017). \u003cem\u003eExploring the Applications of Second-Generation Mindfulness-Based Interventions for\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eGrossoehme, D., \u0026amp; Lipstein, E. (2016). Analyzing longitudinal qualitative data: The application of trajectory and recurrent cross-sectional approaches. \u003cem\u003eBMC Research Notes\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(1), 136. https://doi.org/10.1186/s13104-016-1954-1\u003c/li\u003e\n \u003cli\u003eHanley, A. W., Bernstein, A., Nakamura, Y., Hadash, Y., Rojas, J., Tennant, K. E., Jensen, R. L., \u0026amp; Garland, E. L. (2020). The Metacognitive Processes of Decentering Scale: Development and Initial Validation of Trait and State Versions. \u003cem\u003ePsychological Assessment\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(10), 956\u0026ndash;971. https://doi.org/10.1037/pas0000931\u003c/li\u003e\n \u003cli\u003eHanley, A. W., \u0026amp; Garland, E. L. (2021). The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): Development and Validation of a New Tool to Assess Therapist Adherence and Competence. \u003cem\u003eJournal of Evidence-Based Social Work (2019)\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(3), 308\u0026ndash;322. https://doi.org/10.1080/26408066.2020.1833803\u003c/li\u003e\n \u003cli\u003eHayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., \u0026amp; Strosahl, K. (1996). Experimental avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e64\u003c/em\u003e(6), 1152\u0026ndash;1168. https://doi.org/10.1037//0022-006x.64.6.1152\u003c/li\u003e\n \u003cli\u003eHayes-Skelton, S. A., \u0026amp; Eustis, E. H. (2020). Experiential avoidance. In \u003cem\u003eClinical handbook of fear and anxiety: Maintenance processes and treatment mechanisms\u003c/em\u003e (pp. 115\u0026ndash;131). American Psychological Association. https://doi.org/10.1037/0000150-007\u003c/li\u003e\n \u003cli\u003eHick, S. F., \u0026amp; Chan, L. (2010). Mindfulness-Based Cognitive Therapy for Depression: Effectiveness and Limitations. \u003cem\u003eSocial Work in Mental Health\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(3), 225\u0026ndash;237. https://doi.org/10.1080/15332980903405330\u003c/li\u003e\n \u003cli\u003eHilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A. R., Shanman, R. M., Sorbero, M. E., \u0026amp; Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. \u003cem\u003eAnnals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(2), 199\u0026ndash;213. PubMed. https://doi.org/10.1007/s12160-016-9844-2\u003c/li\u003e\n \u003cli\u003eIbrahim, M. E., \u0026amp; Hefny, M. A. (2022). Central sensitization and adult attention deficit hyperactivity disorder in medical students with chronic back pain: A cross-sectional study. \u003cem\u003eEgyptian Rheumatology and Rehabilitation\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(1), 24. https://doi.org/10.1186/s43166-022-00124-2\u003c/li\u003e\n \u003cli\u003eKabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. \u003cem\u003eGeneral Hospital Psychiatry\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(1), 33\u0026ndash;47. https://doi.org/10.1016/0163-8343(82)90026-3\u003c/li\u003e\n \u003cli\u003eKonstantinou, K., Hider, S. L., Jordan, J. L., Lewis, M., Dunn, K. M., \u0026amp; Hay, E. M. (2013). The impact of low back-related leg pain on outcomes as compared with low back pain alone: A systematic review of the literature. \u003cem\u003eThe Clinical Journal of Pain\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 644\u0026ndash;654. https://doi.org/10.1097/AJP.0b013e31826f9a52\u003c/li\u003e\n \u003cli\u003eLennon, R. P., Fraleigh, R., Van Scoy, L. J., Keshaviah, A., Hu, X. C., Snyder, B. L., Miller, E. L., Calo, W. A., Zgierska, A. E., \u0026amp; Griffin, C. (2021). Developing and testing an automated qualitative assistant (AQUA) to support qualitative analysis. \u003cem\u003eFamily Medicine and Community Health\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(Suppl 1), e001287. https://doi.org/10.1136/fmch-2021-001287\u003c/li\u003e\n \u003cli\u003eMahmutović, E., Safiye, T., Bi\u0026scaron;evac, E., Ajdinović, A., Salihagić, Z., Minić, S., \u0026amp; Dolićanin, Z. (2024). Quality of Life and Functional Status of Patients with Lumbar Radiculopathy. \u003cem\u003eIranian Journal of Public Health\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(8), 1837\u0026ndash;1846. https://doi.org/10.18502/ijph.v53i8.16289\u003c/li\u003e\n \u003cli\u003eMcCracken, L. M., Gauntlett-Gilbert, J., \u0026amp; Vowles, K. E. (2007). The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability. \u003cem\u003ePAIN\u003c/em\u003e, \u003cem\u003e131\u003c/em\u003e(1), 63. https://doi.org/10.1016/j.pain.2006.12.013\u003c/li\u003e\n \u003cli\u003eMohr, E., Matthew, S., Narisetti, L., Duff, C., \u0026amp; Schoenberg, P. (2025). Cognitive mechanisms of mindfulness-based pain management in chronic pain. \u003cem\u003eSocial Sciences \u0026amp; Humanities Open\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 101261. https://doi.org/10.1016/j.ssaho.2024.101261\u003c/li\u003e\n \u003cli\u003eParisi, A., Roberts, R. L., Hanley, A. W., \u0026amp; Garland, E. L. (2022). Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials. \u003cem\u003eMindfulness\u003c/em\u003e. https://doi.org/10.1007/s12671-022-01964-x\u003c/li\u003e\n \u003cli\u003eRiegner, G., Posey, G., Oliva, V., Jung, Y., Mobley, W., \u0026amp; Zeidan, F. (2023). Disentangling self from pain: Mindfulness meditation-induced pain relief is driven by thalamic-default mode network decoupling. \u003cem\u003ePain\u003c/em\u003e, \u003cem\u003e164\u003c/em\u003e(2), 280\u0026ndash;291. https://doi.org/10.1097/j.pain.0000000000002731\u003c/li\u003e\n \u003cli\u003eSagui-Henson, S. J. (2017). Cognitive Avoidance. In V. Zeigler-Hill \u0026amp; T. K. Shackelford (Eds.), \u003cem\u003eEncyclopedia of Personality and Individual Differences\u003c/em\u003e (pp. 1\u0026ndash;3). Springer International Publishing. https://doi.org/10.1007/978-3-319-28099-8_964-1\u003c/li\u003e\n \u003cli\u003eSchmid, A. B., Tampin, B., Baron, R., Finnerup, N. B., Hansson, P., Hietaharju, A., Konstantinou, K., Lin, C.-W. C., Markman, J., Price, C., Smith, B. H., \u0026amp; Slater, H. (2023). Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. \u003cem\u003ePain\u003c/em\u003e, \u003cem\u003e164\u003c/em\u003e(8), 1693\u0026ndash;1704. https://doi.org/10.1097/j.pain.0000000000002919\u003c/li\u003e\n \u003cli\u003eSch\u0026uuml;tze, R., Rees, C., Preece, M., \u0026amp; Sch\u0026uuml;tze, M. (2010). Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain. \u003cem\u003ePain\u003c/em\u003e, \u003cem\u003e148\u003c/em\u003e(1), 120\u0026ndash;127. https://doi.org/10.1016/j.pain.2009.10.030\u003c/li\u003e\n \u003cli\u003eSuso-Ribera, C., Camacho-Guerrero, L., Osma, J., Suso-Vergara, S., \u0026amp; Gallardo-Pujol, D. (2019). A Reduction in Pain Intensity Is More Strongly Associated With Improved Physical Functioning in Frustration Tolerant Individuals: A Longitudinal Moderation Study in Chronic Pain Patients. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e, 907. https://doi.org/10.3389/fpsyg.2019.00907\u003c/li\u003e\n \u003cli\u003eTarulli, A. W., \u0026amp; Raynor, E. M. (2007). Lumbosacral radiculopathy. \u003cem\u003eNeurologic Clinics\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(2), 387\u0026ndash;405. PubMed. https://doi.org/10.1016/j.ncl.2007.01.008\u003c/li\u003e\n \u003cli\u003eVowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., Ney, J. P., \u0026amp; van der Goes, D. N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. \u003cem\u003ePAIN\u003c/em\u003e, \u003cem\u003e156\u003c/em\u003e(4). https://journals.lww.com/pain/Fulltext/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx\u003c/li\u003e\n \u003cli\u003eWexler, R. S. (2022). Protocol for mindfulness-oriented recovery enhancement (MORE) in the management of lumbosacral radiculopathy/radiculitis symptoms: A randomized controlled trial. \u003cem\u003eContemporary Clinical Trials Communications\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWexler, R. S., Fox, D. J., ZuZero, D., Bollen, M., Parikshak, A., Edmond, H., Lemau, J., Montenegro, D., Ramirez, J., Kwin, S., Thompson, A. R., Carlson, H. L., Marshall, L. M., Kern, T., Mist, S. D., Bradley, R., Hanes, D. A., Zwickey, H., \u0026amp; Pickworth, C. K. (2024). Virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) reduces daily pain intensity in patients with lumbosacral radiculopathy: A randomized controlled trial. \u003cem\u003ePain Reports\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(2), e1132. https://doi.org/10.1097/PR9.0000000000001132\u003c/li\u003e\n \u003cli\u003eWilson, J. M., Haliwa, I., Lee, J., \u0026amp; Shook, N. J. (2023). The role of dispositional mindfulness in the fear-avoidance model of pain. \u003cem\u003ePLOS ONE\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), e0280740. https://doi.org/10.1371/journal.pone.0280740\u003c/li\u003e\n \u003cli\u003eYong, R. J., Mullins, P. M., \u0026amp; Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States. \u003cem\u003ePain\u003c/em\u003e, \u003cem\u003e163\u003c/em\u003e(2), e328\u0026ndash;e332. https://doi.org/10.1097/j.pain.0000000000002291\u003c/li\u003e\n \u003cli\u003eZale, E. L., Lange, K. L., Fields, S. A., \u0026amp; Ditre, J. W. (2013). The relation between pain-related fear and disability: A meta-analysis. \u003cem\u003eThe Journal of Pain\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(10), 1019\u0026ndash;1030. https://doi.org/10.1016/j.jpain.2013.05.005\u003c/li\u003e\n \u003cli\u003eZeidan, F., Baumgartner, J. N., \u0026amp; Coghill, R. C. (2019). The neural mechanisms of mindfulness-based pain relief: A functional magnetic resonance imaging-based review and primer. \u003cem\u003ePain Reports\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(4), e759. https://doi.org/10.1097/PR9.0000000000000759\u003c/li\u003e\n \u003cli\u003eZeidan, F., Emerson, N. M., Farris, S. R., Ray, J. N., Jung, Y., McHaffie, J. G., \u0026amp; Coghill, R. C. (2015). Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. \u003cem\u003eThe Journal of Neuroscience : The Official Journal of the Society for Neuroscience\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(46), 15307\u0026ndash;15325. PubMed. https://doi.org/10.1523/JNEUROSCI.2542-15.2015\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"back pain, radiculopathy, mindfulness, non-pharmacologic management, qualitative analysis, longitudinal analysis","lastPublishedDoi":"10.21203/rs.3.rs-7104279/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7104279/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: 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.\u003c/p\u003e","manuscriptTitle":"\"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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 11:05:18","doi":"10.21203/rs.3.rs-7104279/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69f78d9d-f05e-4fbb-ba9d-87e95f91adc3","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:03:54+00:00","versionOfRecord":{"articleIdentity":"rs-7104279","link":"https://doi.org/10.1007/s12671-026-02782-1","journal":{"identity":"mindfulness","isVorOnly":false,"title":"Mindfulness"},"publishedOn":"2026-03-06 15:59:44","publishedOnDateReadable":"March 6th, 2026"},"versionCreatedAt":"2025-08-01 11:05:18","video":"","vorDoi":"10.1007/s12671-026-02782-1","vorDoiUrl":"https://doi.org/10.1007/s12671-026-02782-1","workflowStages":[]},"version":"v1","identity":"rs-7104279","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7104279","identity":"rs-7104279","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}