'Could I be imagining this?' - the dialectic struggles of people with persistent unexplained back pain.

PURPOSE: To explore how patients with persistent unexplained pain interpret and utilise the biopsychosocial model. This might have an impact on the outcome from treatment programmes that adopts a biopsychosocial approach. METHOD: We conducted three interviews with 20 patients attending a pain management programme for persistent unexplained back pain; prior to attending the course, immediately following the course and at 1 year. We used the methods of grounded theory. RESULTS: Patients battled through several dialectic tensions in an attempt to legitimise their pain: First, patients wanted a medical diagnosis but also recognised that psychosocial factors contributed to their pain. Second, although the outward appearance of pain was important to legitimacy, it was also important not to appear 'too ill'. Third, meeting others with unexplained pain reinforced credibility, but patients also described how they were not 'like the others'. Finally, although holding on to one's self was important, patients also described an acceptance of loss. CONCLUSIONS: These dialectic tensions are likely to have an impact on a person's decision to embrace the biopsychosocial model, and might therefore effect their outcome. Health care professionals should be sensitive to the cultural ambiguity of patients with persistent unexplained pain.