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Disabil Rehabil, Early Online: 1–8

! 2013 Informa UK Ltd. DOI: 10.3109/09638288.2013.793750

RESEARCH ARTICLE

(Un)doing gender in a rehabilitation context: a narrative analysis

of gender and self in stories of chronic muscle pain
Birgitte Ahlsen, Hilde Bondevik, Anne Marit Mengshoel, and Kari Nyheim Solbrække

Institute of Health and Society, University of Oslo, Oslo, Norway

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Abstract Keywords
Purpose: To explore how gender appears in the stories of self-told by men and women Femininity, gender, masculinity, muscles, pain
undergoing rehabilitation for chronic muscle pain. Method: The material, which consists of
qualitative interviews with 10 men and 6 women with chronic neck pain, was analyzed from a History
gender sensitive perspective using narrative method. The analysis was inspired by Arthur
Frank’s typologies of illness narratives (restitution, chaos and quest). Findings: The women’s Received 14 October 2012
stories displayed selves that were actively trying to transcend their former identity and life Revised 27 March 2013
conditions, in which their pain was embedded. Their stories tended to develop from ‘‘chaos’’, Accepted 4 April 2013
towards a quest narrative with a more autonomous self. The selves in the men’s stories Published online 20 May 2013
appeared to be actively seeking a solution to the pain within a medical context. Framed as a
restitution narrative, rooted in a biomedical model of disease, the voice often heard in the
For personal use only.

men’s stories was of a self-dependent on future health care. Our findings contribute greater
nuance to a dominant cultural conception that men are more independent than women in
relation to health care. Conclusion: Understanding the significance of gender in the construction
of selves in stories of chronic pain may help to improve the health care offered to patients
suffering from chronic pain.

ä Implications for Rehabilitation

 Patients tell stories that powerfully communicate their particular illness experiences.
 Cultural expectations of femininity and masculinity play a significant role with regard to how
the patients construct their stories, which may be important to health professionals’
perceptions of the patients’ problem.
 Health care professionals should listen carefully to the patient’s own story and be sensitive
to the significance of gender when trying to understand these people’s health problem.

Introduction seeking rehabilitation services because of chronic muscle pain

in the population as a whole, then they indicate a significant
Background
gender difference in men’s and women’s use of health services.
Chronic muscle pain is a major health problem in Norway, as in
many other west European countries, and it is one of the most Gender and health-seeking activity
13
20
common reasons that people take sick leaves, participate in
The predominant conception of men’s and women’s health-
rehabilitation and receive disability pension [1–3]. Population-
seeking activity has for some time been that men are more
based studies from Norway and Sweden suggest that the
reluctant to seek help than women regardless of nature of their
prevalence of chronic muscle pain among both adult women
health concern [11–15]. It has been argued that men view seeking
and men might be as high as 25% [2,4,5]. There are, however,
health care as a feminine practice, one which is in conflict with
a significantly higher percentage of women who report receiving
cultural expectations that men be independent and self-reliant
physiotherapy for their chronic pain than men do [5,6]. Similarly,
[11]. Conversely, the general understanding of women is that they
in studies focusing on rehabilitation of people with chronic
report having poorer health and are more likely to obtain formal
muscle pain, the dominance of women is striking [7–10], that is
health care than men [16,17], which may be associated with
women either constitute the sample as a whole [7,9], or they make
female weakness and dependency. Critical voices claim, however,
up to more than twice as many as the men [8,10]. If these studies
that this picture is oversimplified, and demonstrate that men’s and
accurately reflect the relative proportions of women and men
women’s health behavior is related to the particular symptom
or condition in question and to the age of the patient [18,19].
For example, among people with cancer of the colon or rectum,
Address for correspondence: Birgitte Ahlsen, PhD Student, Institute of
Health and Society, University of Oslo, P.O. 1089 Blindern, 0318 Oslo, women were no more likely than men to recognize and respond
Norway. Tel: +47-905-01-583. Fax: +47-22-85-50-91. E-mail: birgitte. to the cancer symptoms, and women were actually more likely
ahlsen@medisin.uio.no than men to delay seeking care [20]. To obtain a more nuanced
 2 B. Ahlsen et al.
picture of how gender intersects with men’s and women’s
interpretation of chronic pain and their relationship to health
care, individual experiences must be examined [21].
Men’s and women’s experiences of being in treatment
because of chronic pain
Studies of patients’ experiences of being in treatment because
of chronic pain focus mainly on women. These studies highlight
the women’s frequent past history of not being believed or having
their experience of pain taken seriously [7,9,22–26]. For this
reason, having one’s experience finally recognized by health
workers and co-participants in the treatment program is reported
to enhance the women’s confidence in themselves, to change their
relationships to their own bodies and furthermore, their relation-
ships with others around them [7,9,27]. Paulson et al.’s study [28]
of men living with fibromyalgia-type pain emphasizes the men’s
fear of being perceived as whiners or lazy in their medical
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encounters, which indicate that men with chronic pain also
experience an ongoing struggle to be believed and taken seriously
in a medical context. However, despite these initial findings, we
have as yet only limited knowledge of the significance of gender
in men’s and women’s relationships to medicine and health care
professionals. For example: are men who take part in rehabilita-
tion programs because of chronic pain more autonomous in their
daily life, and less dependent on health care than women? Or is
the gender aspect in this topic more nuanced, as has been
suggested by others. Using a specific Norwegian rehabilitation
clinic as the point of entry, the aim of this article is to develop
new knowledge of the significance of gender as revealed in men’s
For personal use only.
and women’s stories of living with chronic pain, and being in
rehabilitation to deal with that pain. To illuminate the complexity
within the men’s and women’s narratives, that is how they draw
on, or resist cultural norms of masculinity and femininity as they
narrate their selves and experiences, we use narrative methods
[29,30]. The questions to be illuminated in this article are: ‘‘How
do men and women in a rehabilitation context due to chronic
pain narrate their selves, and how are claims about their
selves interrelated with cultural constructions of gender in their
stories?’’.
Theoretical framework
This article is analytically framed by a gender-sensitive narrative
perspective, in which individual stories of illness are seen as a
fundamental way of giving meaning to experiences related to
pain and suffering. A narrative is a process that links together
a person’s past history, present situation and anticipated future
into a coherent whole [31]. Although, there are many ways
to define a narrative, scholars seem to agree that narrative is an
organizational scheme, in which sequences of events are tempor-
ally structured with a beginning, middle and end [30,31]. Arthur
Kleinman very early pointed to how chronic illness may
dramatically change the relationship between the ill person’s
self and the world, bringing up to date questions such as ‘‘who am
I?’’ and ‘‘who may I become?’’ [32]. Telling stories about own
illness, Kleinman claims, is a way for the chronically ill to create
meaning in life and cope with their particular experiences [32].
Although illness narratives, and especially those of long-term
illnesses, are individual and thus unique, each of them is at the
same time a variation that utilizes some of the tropes of common
cultural stories that explain how life proceeds [14,32–34]. It is
also important to recognize stories of illness as social acts that
present not only individual experiences associated with illness,
but also the self-image that the narrator hopes to project to
others [33]. As pointed out by Frank, ‘‘the self story is not told
for the sake of description, though description may be its
Disabil Rehabil, Early Online: 1–8
ostensible content. The self is being formed in what is told’’ [14].
This means, the telling of an illness story is also the performing
of a self. Thus, relating Frank’s argument to a gender perspective,
in which gender is seen as the product of a self-presentation
process [35], illness stories can also be seen as enactments of
cultural norms of masculinity and femininity.
However, an overemphasis on gender as a cultural construction
runs the risk of excluding the significance of gendered bodily
differences. To avoid this, for the gendered aspect of the
framework, we draw on the theoretical positions developed
by Simone de Beauvoir and her successors, in which gender is
associated not only with the process of doing femininity and
masculinity, but also to the specific human body, or bodily self
[36,37,44]. In order to address the extent to which men and
women with chronic pain develop an autonomous self-indepen-
dent of the health care system, we are also inspired by Beauvoir’s
conceptualization of immanence and transcendence, which,
according to her, are historically related to norms of femininity
and masculinity. Immanence refers to an ‘‘in-itself’’, a deadlocked
position in which the person is deprived the opportunity to make
free choices. Beauvoir claims that, by being defined as ‘‘the
other’’, women have been condemned to a state of immanence
throughout history [37]. In the context of men’s and women’s
stories of chronic pain, immanence may correspond to a process
in which the self develops a dependency relationship to health
care, without any significant changes in actual health. Conversely,
Beauvoir describes transcendence as the ability to extend beyond
oneself in order to achieve new possibilities. According to
Beauvoir, this position has been the privilege of men throughout
history. In the context of stories of chronic pain, the process in
which the patients comes to see their pain as a source of achieving
new knowledge about themselves, and through participating in
rehabilitation, explores new ways of being, can be seen as an
expression of transcendence.
Method
Participants
The empirical data of this article consists of individual qualitative
interviews of 10 men and 6 women with chronic neck pain who
have been through a rehabilitation program at a rehabilitation
clinic. As one of the proclaimed goals of the clinic was to increase
the person’s capacity for work, the rehabilitation context was
characterized by an anticipated optimism, and being motivated
was an important criterion for referral to this clinic. The
participants in the present study were between 28 and 50 years
old. They were recruited with the assistance of their physiother-
apists at the rehabilitation clinic, who turned to those men and
women with neck pain who appeared open and willing to share
their illness experiences. Most of the participants were skilled
workers, some were craftsmen, and one had tertiary education.
All were of Norwegian ethnicity. Many of the participants were
on long-term sick leave at the time of the interview.
Interviews
To investigate men’s and women’s accounts of being in rehabili-
tation, we conducted qualitative interviews, inspired by Kvale and
Brinkmann [38] and Holstein and Gubrium [39]. The interview
guide was organized around different themes, such as pain
experiences, and experiences related to being in treatment. During
each interview, the interviewer took on the role of an active
listener, and attempted to assist the participants in telling their
story in their own way, less by leading the discussion than by
following the participants down their own trail [30]. Additionally,
to encourage the participants to elaborate on their experiences in
 DOI: 10.3109/09638288.2013.793750
their own words, the interviewer kept her questions as open as
possible, for instance: ‘‘Can you please tell me about your pain?
Can you tell me about your experiences at the rehabilitation
clinic?’’ [38]. The study was introduced to the informants as a
study on patients with chronic neck pain, the aim of which was to
find out more about men’s and women’s experiences of living
with and undergoing treatment for chronic neck pain. All but three
of the interviews were carried out in a room at the rehabilitation
clinic that was usually used by physiotherapists for examinations
and treatment. One interview took place in the informant’s home,
another at the interviewer’s work place and the third in a cafeteria.
The interviews were carried out by the primary author, who is also
a physiotherapist, which many of the informants were aware of.
The interviews lasted between 90 and 120 minutes. All interviews
were tape-recorded and accurately transcribed by the interviewer.
Transcription was completed shortly after the interview, which
allowed the interviewer to remember important non-verbal
aspects of the narrative event, such as the participant’s tone
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of voice, breathing and pauses, as well as the interviewer’s own
immediate responses.
Narrative analysis
Our analysis is inspired by Riessman [30,40] and Frank [41] and
takes an interest in both the content of the men’s and women’s
stories – that is what is told in response to the interviewer’s
questions – and also how the stories are told. The latter refers to
the organization of events in the building of the story’s plot.
In particular, our analysis was conducted by posing the following
question in relation to the material: ‘‘Why is the story constructed
For personal use only.
in this manner and what claims about the self are effectuated
by this story?’’ First, all the interviews were read in order to get
an overall impression of what they were about. At this stage we
noted that in terms of content the men’s and women’s stories
included many elements in common, such as an accident,
a demanding job situation and often also painful life events.
When the men’s and women’s stories described participating in
rehabilitation, they typically referred to the significance of being
with ‘‘a multidisciplinary team’’ and receiving treatment from the
experts. However, whereas the women’s stories often expressed
a change of self, the selves in the men’s stories did not seem to
undergo any powerful changes.
To elucidate the broader social significance of these findings,
we utilized Frank’s typologies of illness narratives as character-
ized by our time, that is: chaos, quest and restitution narratives
[14,41]. In short, the restitution story, which is the grand narrative
within medicine, has a plot of ‘‘someone getting sick, being
treated, and having some version of health restored’’ [41]. In this
narrative illness is understood as an aberration, which for the
teller means to a greater or lesser degree, a return to the status
quo. By contrast, in the chaos narrative the self is interwoven with
multiple problems and life appears as if it will never get any
better. While restitution stories presuppose the control that is
necessary to effect restitution, a chaos narrative expresses lack
of control [14]. On the other hand, the quest narrative depicts
illness as the occasion of a journey through which something is
gained. The self claimed in quest narratives is actively remaking
the past in light of the present, in order to create coherence and
new meaning, and the narrative commonly expresses a changed,
renewed self. Although Frank believes that no actual telling
conforms exclusively to any of these narrative tropes, but rather
is some combination of the three, and that some include other
narrative types as well, he claims that these typologies are
hegemonic ways that people living in a medicalized world deal
with their illnesses. It is important to recognize these typologies
as simplified patterns that do not reflect the complexity of specific
(Un)doing gender in a rehabilitation context 3
experiences and narratives. Moreover, and most interestingly,
Frank claims that self change in illness narratives is unrelated to
gender [42]. However, as already mentioned, according to
Beauvoir’s critical perspective on universal, gender-blind claims
about humanity and the self, a self actively searching for new
scopes of action has historically and culturally been associated
with men and masculinity. Beauvoir’s description matches
Frank’s quest narrative, so this particular narrative type could
be expected to be typical of men’s stories of chronic pain. Chaos
narratives that display a somewhat bewildered self, on the other
hand, locked in by an overwhelming situation, seem more closely
related to the historical construction of femininity, as outlined by
Beauvoir. Thus, one could expect chaos narratives to be
associated with women, and avoided by men, among those who
live with chronic pain. However, as already indicated during the
initial analysis, this preconception about gender and illness was
only partly confirmed. To address the relationship between illness
stories and gender in a broader sense, we have integrated Frank’s
typologies as part of our analysis.
Narrative analysis is case oriented [29,30], and to represent our
findings in a way that show how gender interrelate with
constructions of selves in stories of chronic muscle pain we
have chosen to present the individual ‘‘self-story’’ of one female
and one male participant, Linda and David. Linda and David both
have high school education. Their stories share rich descriptions
of experiences related to living with chronic pain and being in
rehabilitation, which is of great importance for narrative analysis.
In particular, the selection of stories for presentation is based on
an interactive process of hearing stories correspond with the
original research interest, and representing these stories in writing
for analytic purposes [43]. We agree with Frank’s position in
which he claims that analysis of stories takes place during the
attempt to write these stories, and as such our findings are not post
hoc addendums to an analysis that was completed before the
writing process began [43]. Importantly though, in line with
narrative methods [30], Linda’s and David’s story are chosen
because they powerfully illuminate theoretical suppositions on
gender in men’s and women’s stories of chronic pain and
participating in rehabilitation. As individual stories of chronic
pain are personal and unique, they will never be alike. Still, as the
dynamic of self and gender demonstrated in Linda’s and David’s
stories can be found in the other women’s and men’s stories in this
study, we find the results to be of relevance for the sample as a
whole. Although the men’s and women’s stories were analyzed in
relation to each other, we will for the sake of clarity present the
story of Linda and David separately, beginning with Linda’s story.
Findings
Linda’s story
Linda is a woman in her thirties, married, with children. After
finishing high school, Linda started working in a warehouse,
where she became manager of one of the departments. During the
interview, Linda introduced her neck pain as something that was
always part of her life, and something she had grown used to. The
origin of neck pain is by Linda related to, among other things, one
particular incident from her childhood, and to a generally
physically active life that led to assorted accidents and blows to
the head. More striking in Linda’s story are, however, accounts of
a relational self.
A wounded woman
I’ve found out it’s all about stress. Pressure to constantly
achieve something new. Because I had no [higher] education,
I’ve worked my way up and delivered good results for 15 years,
 4 B. Ahlsen et al.
but of course it could not continue [forever]. . .. I’ve driven
myself very hard. We’ve been through that here at the
clinic–realizing that I’ve gone too far with myself. . . .I’ve
said yes to everything and everyone and I’ve fixed everything,
I just reorganized my days. Often it has affected those at home,
the kids and my husband, because I’ve not been able to spend
enough time with them, because I’ve said yes to helping
everyone else. . . . I don’t know how many times I’ve been
to the doctor with these symptoms, and all they’ve done is to
touch the place and say ‘‘you’re tired and stiff.’’ Then they
give me a sick leave and send me out. Nothing more. I never
got any answers, just deferment of the problem like ‘‘take 14
days off work and rest.’’ But that didn’t help me to improve.. . .
Nobody listened to me – nobody, neither the doctor nor my
husband, so the situation gradually became very tense. I did
not want to talk about it, and outwardly I was very happy and
nice—I kept up a show of good humor. I kept going. Because
the pain is invisible, and I’m not a person to whinge and whine,
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I try to hide it and try to do my best. The pain has been there
for so many years, and I’ve tried to suppress it. I can’t do
anything about it.
By referring to a tendency to push to the limit and always
saying yes, chronic pain is in Linda’s story clearly ascribed an
altruistic self, with connotations to cultural norms of femininity.
Further consideration of the life situation that unfolds in Linda’s
story even give the impression of an irrational self that lacks
control of its pain and the situation it finds itself in. Moreover,
the self depicted in the beginning of Linda’s story appears, in the
words of Frank, ‘‘swept along, without control, by life’s
For personal use only.
fundamental contingency’’ [14], which is indicative of a chaos
narrative. The sense of chaos is reinforced by descriptions of
the doctors’ inability to help and a lack of support from others.
The sequence bears witness to a deadlocked situation. Linda’s
story is also chaotic in the sense that it lacks a temporal ordering
of sequences and a prominent causality. Structurally, Linda’s story
is not a ‘‘proper’’ story, and may as such be difficult for the
listener to hear [14]. More significantly, as pointed out by Frank,
‘‘the teller of the chaos narrative is not heard to live a proper life,
since in life as in story, one event is expected to lead to another.
Chaos negates that expectation’’ [14].
In the perspectives of Beauvoir, though, a suffering self
may also be a passive self, which means a self acted upon and
governed by others, rather than being autonomous in own life.
This position is historically and culturally associated with
femininity [44]. On the other hand, by referring to a persistent
struggle to keep up appearances and to keep the wheels in motion,
the voice heard in Linda’s story is also that of a self not giving
in to the difficult circumstances. Still, in Beauvoir’s perspective,
by enacting a self in which the outward appearance is dissociated
from its internal reality, Linda’s story bears witness to an
alienation process [37]. This phenomenon is by Beauvoir linked
to the woman’s effort to emerge as an object in the eye of others,
and in doing so becomes in-authentic and dependent on acknow-
ledgement from others [37].
In sum, the beginning of Linda’s story clearly demonstrates
what Beauvoir calls women’s tragedy, which is the conflict
between a profound human need to assert oneself as significant,
and the claims of a society that treats her as insignificant [37].
There is a shift, however, in Linda’s story when it moves on to
describe her experiences at the rehabilitation clinic.
The turning point: restoring a self
When I went into the doctor’s office I thought, ‘‘Oh well, it’s
probably the same examinations and the same answers’’. I did
Disabil Rehabil, Early Online: 1–8
not feel very positive about the meeting, in my mind, at least.
But then the doctor said ‘‘Your mobility is extremely good,
and I can’t find anything wrong with you—there is no
tendinitis, no injury to the nerves, but that does not mean
you’re well or that you don’t feel pain. No.’’ And I was like,
oh my god, is it true? Is there a person who actually believes
me?. . . (What is better here is that) You are treated by a whole
team. You were taken care of and solutions were discussed
together. There was a doctor, a physiotherapist, a training
teacher, and a psychologist who jointly developed a program
they felt would suit me. Everybody receives an individual plan
and we are evaluated on that basis, whether we are moving in
the right direction: Are you any better? Is anything worse?
How are you feeling? and things like that.. . . (Socially) We are
a group of people with the same symptoms. It’s tremendously
positive, because we get to know each other, and it becomes
a nice social atmosphere and you feel you’re not alone or out of
place. We exchange experiences and talk and have a good time.
The changes in Linda’s story are evident in her descriptions
of interpersonal encounters related to being a participant at the
rehabilitation clinic. First, a meeting with a doctor who actually
seems to believe in her pain seems to mark a significant turning
point. In addition, the experience of being taken care of by several
different health professionals, and not just one person, as well as
experiences of being part of a larger community, figure promin-
ently in Linda’s story. While these events in Linda’s story
represent a positive change, they may at the same time, by
emphasizing relational aspects of being in treatment, accentuate a
dependent self. However, by referring to different activities of the
health professionals, such as ‘‘team discussions’’, ‘‘working out
treatment plans’’ and ‘‘evaluation of results’’, Linda’s story enacts
the plot of a restitution narrative, which importantly predicts a
more optimistic future. Worth noting, however, is the change in
Linda’s telling from first person to the second person, ‘‘you’’
form. By doing so Linda creates a distance between herself and
the topic, which may indicate a self submitting to a regimen
created by a team of experts. Nevertheless, the situation in Linda’s
story seems less chaotic. Further examination of the evolving self
in Linda’s rehabilitation story shows that it actually transcends
this shift in narrative form.
Towards an autonomous self
(Here at the clinic) They see the kind of person I actually am.
I’ve always been a non-stop kind of person, but to have that
confirmed, that I actually drive myself too hard. That has
been very positive. . .. I’ve learned to take time to relax, I need
to slow down. Usually you don’t get much more done by
stressing. I’ve learned now that it’s possible to get just as much
done when I don’t raise my shoulders and stress and stop
breathing.. . .I have got some exercises to take home, so that
I have something to train with. We have learned that it is not
necessary to go to the training studio and train with balls and
that kind of thing. The important thing is that we are active in
one way or another. If we ride a bike or go jogging or skiing,
[that’s ok too.] It is not what you do but that you are actually
doing something [active] that counts.
As shown in the sequence above, Linda’s story depicts a self
who, through the rehabilitation process, has learned the deeper
meaning of her suffering [14]. The lesson learned, as recounted by
Linda, seems to be integrated into herself and her personal history
of pushing too hard for too long in order to keep up appearances.
By referring to a change of self, Linda’s story ends as a quest
narrative, which, according to Frank, bears witness to a
 DOI: 10.3109/09638288.2013.793750
responsible self that actively incorporates pain into its personal
life in order to improve it [14]. The anticipated future delineated
in Linda’s story emphasizes the arrival of a renewed self, one that
is more independent from medicine, and more autonomous than
it had been in the past. Yet again, in this sequence we notice
a change in telling form, from first person to second person, or to
plural – we – which may indicate that Linda’s story at this point
also bears witness to a self submitted to a specific regimen.
Although there were variations in our sample, the women’s
stories tended to depict a self actively trying to transcend her
former self and the life conditions in which chronic pain has
embedded itself.
David’s story
David is a man in his forties, married, with children. His
education extends to one year of economics after finishing high
school. In David’s narrative, his career in marketing and finance,
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which appears to have been successful, came to an abrupt end a
year before due to neck troubles.
An injured man
I’ve had two neck accidents; one was a (compression)
fracture 7 years ago, which never really healed, I didn’t take
the time to be rehabilitated and properly restituted because
I was on a very important—according to myself—career path,
which I felt I had to continue with. Then, one year ago there
was another neck accident, not with any fracture or anything,
but the old injury plus the new one is the reason that I have
For personal use only.
been on sick leave since last year and had quite a lot of trouble
with my neck. . . . (There is another problem) The industry
(in which I work) has been hit hard by the financial crisis,
and the market began to turn significantly, so we didn’t get the
results we were supposed to achieve and in connection with
that there was a conflict with my leader, which is no good
of course. But now I have to focus on getting well, at least well
enough to find another job. . .. (Previously)I’ve been through
quite a long period of treatment. I think the results would have
been better if the physiotherapist had had fewer patients to deal
with, so he could have followed up on me and others more
closely, because it is very easy to make mistakes during
exercise if, for example, you are not careful and you don’t have
constant supervision.. . .So I checked up on a couple of other
places, to try to find out what happened (to my neck), in order
to take a more purposeful approach to it. . . .(At home) My
children often want to play and hang from my neck and sit on
my neck, but that of course is absolutely out of the question,
so we try to find other things to do, but they are aware of the
situation in a way. They understand. But of course I register
that if there has been a bad period of three or four days in a
row, my fuse is very short, and they end up paying for that.
It has probably happened that several people have received an
unwarranted telling off. I don’t go crazy, but I lose my temper
more often and my reactions are more forthright. And that is
not pleasant at all.
By emphasizing two following accidents chronic pain is in
David’s story directly ascribed a sudden breakdown of his
physical body, which is the implicit origin of illness in a
restitution narrative [14]. The body in a restitution narrative
is dissociated from the self and becomes an ‘‘it’’ to be treated.
This is in accordance with the disease model of medicine, which
as pointed out by Frank, articulates well with the modernist
understanding of the individual as an autonomous entity [14]. As
pointed out earlier, an autonomous self may articulate well with
(Un)doing gender in a rehabilitation context 5
cultural norms of masculinity. Closer examination of David’s
story shows, however, that the autonomy of the teller is fragile.
For example, by referring to a stressful working situation and
a personal conflict with the leader at work, the voice heard
in David’s story is also that of a self struggling in its relation to
other people. Structurally though, David’s story displays a
temporal organizing of events, with causal connections (the
accidents is the cause of David’s trouble). This means, David is
telling a proper story, which not only is easy to listen to, it may
also give the impression of a self being in control of the situation.
By referring to episodes of losing temper, the teller’s degree
of control is, however, nuanced. Moreover, by displaying a
struggle to handle the social part of life while in constant pain;
a fragile and emotional self emerges from David’s story. Still,
by regularly asserting an aim of identifying ‘‘what has happened
to the neck’’ and by defining the situation as ‘‘standing at
a crossroads’’, David’s story reasserts a masculine theme of self-
reliance and independence. The self in a restitution narrative,
remains, however, dependent on the activities of the health
professionals [14]. David’s narrative adheres to this rule, and his
close and dependent relationship to health care professionals
becomes apparent when he recounts spending very long periods
in treatment.
In sum, the men’s stories in our study bear witness to an
autonomous self, whose aim is to solve the puzzle of its pain.
The solution to the problem appears, however, to lie within
the medical system. In general, although experiences related
to the rehabilitation clinic in the men’s stories are described in
a positive tone of voice, they do not seem to transcend the
framework of a restitution narrative.
Making good progress
What feels better here is that it’s more of an inter-disciplinary
team. So there are more opinions that can be brought forward.
Their results have been well established and proven over
several years, and there’s a lot of people employed here, which
means, at least for me, that there’s more continuity in both the
training and treatment. That way you’re not dependent on just
one person to get training and get things to work. . . . (For me)
It’s about overcoming the daily neck pain and the headaches
that I experience almost every day, and rebuilding muscle
strength. I want to get that done right and find a level of
functionality I can live with, where I can return to working life
and do a proper job. Maybe not exactly the same as before, but
at least something that I can enjoy. . . (With regard to the social
aspect)Even if I don’t get to know the people here very well,
I am in an environment where, crudely speaking, I can see I’m
not the sickest person on the planet. There are other people
suffering more than I am, and as horrible as it sounds, that
motivates me purely because in some ways I am better off.
I do extremely well physically and I feel a tremendous sense
of achievement about it since I’m used to being ill and
consider myself to be in poor condition, with a reduced ability
to function for very long periods of time. So it is actually quite
good to see other people struggling too. And you have a kind
of common goal which is to get better and get out of here.
The most important part of becoming a participant at the
rehabilitation clinic, according to David’s story, initially appears
to be increased access to professional expertise and a multidis-
ciplinary team. The remedy to chronic pain is, in David’s story,
clearly defined as physical training, which may reflect a
masculine way of achieving health. Moreover, by linking profes-
sional expertise directly to ‘‘training and treatment’’, and as such
keeping the relational self in the background, David’s story keeps
 6 B. Ahlsen et al.
up the claim of an autonomous self. Ways of describing the
relational aspects of being a participant at the rehabilitation clinic
show, however, also a self suffering from being different from
others. Importantly though, rather than concluding in the present,
through utterances of ‘‘overcoming neck pain and headaches’’,
‘‘rebuilding muscle strength’’ and ‘‘get out of here’’, David’s
story projects imaginatively into the future, as is common
of restitution narratives. Although the present in David’s story
consists largely of waiting future results, experiences related
to being in rehabilitation are also narrated as a learning process.
The lesson learned, however, seems mainly turned in upon the
physical body.
In need of future health care
My stay here at the clinic helps me have a more optimistic
outlook about getting better, being able to deal with the
pains and avoid, to a greater degree, the situations that trigger
Disabil Rehabil Downloaded from informahealthcare.com by University of North Carolina on 05/30/13
them in the first place. [I’m more confident] that I can keep up
a consistent level of activity and not just be like a yo-yo,
like with dieting, where you exercise intensively for a period of
time and once you’ve gotten healthier or dropped the weight
you quit and go back to your old routines. Being here gives me
a stronger sense of continuity in my training efforts and I’m
doing it more correctly now so that I can prevent future pain
more than I have before.. . .I hope that my stay here will be
longer because I don’t think I will be in fighting shape in three
weeks. I can’t imagine when it has taken this long already,
that they will be able to fix me so quickly. . .. And then there
For personal use only.
are opportunities to train here under more or less professional
guidance, as a continuation of what I’m doing now. It seems
more sensible than a training center. Here I’ve got the team
I can turn to for support and there are people here who know
my history so I don’t need to repeat all that again. So I’m sure I
will continue with this.
In David’s story, the responsibility of the self seems to be
limited to keeping up with the training program, while it
ultimately seems to be the health professionals’ responsibility
‘‘to fix the problem’’. In the words of Frank, ‘‘the teller of a
restitution narrative lives out illness as a matter of doing their job
as a patient, preparing for the future after illness, and getting
through their own days’’ [14]. As such, the active self described
in David’s story is subsumed to the more prominent activity of the
health professionals. In sum, despite in many ways describing
an autonomous, active, take-charge self, the men’s stories in
general conclude by describing a self that is dependent on medical
professionals for its wellbeing. As such, the men’s stories,
although they are varied and nuanced, can be seen to demonstrate
Beauvoir’s concept of immanence – that is, a self not able to
transcend its present living conditions.
Discussion
The women’s stories in our findings displayed selves that were
actively trying to transcend their former identities and life
conditions in which their troubles were presumably embedded.
Moreover, the women’s stories tended to move away from
‘‘chaos’’, with traces of a dependent self, towards a quest
narrative and a self more independent of others. The men’s stories
tended to display selves that were actively working to find a
solution to the problem within the context of medicine. Framed
as a restitution narrative, and deeply rooted in a biomedical
model of disease, the self depicted in the men’s stories often
appeared dependent on future health care services. As such, our
findings contribute greater nuance to a dominant cultural
Disabil Rehabil, Early Online: 1–8
conception that men are more independent than women in
relation to health care.
The changes in the women’s stories from chaos to quest,
as demonstrated in our findings, have parallels to the narratives
of people living with chronic fatigue syndrome/myalgic enceph-
alomyelitis (CF/ME) [45]. In those stories chaos narratives,
expressing anger, isolation and depression, seemed to figure
prominently prior to diagnosis. The diagnosis, on the other hand,
seemed to enable people with CF/ME to ‘‘move on’’, which often
was expressed as a quest narrative [45]. In addition, the women’s
narration of self-change, as demonstrated in our findings,
resonates with the stories women with chronic pain tell in several
other studies [9,22,23,46].
A change of self may represent a fruitful way of dealing with
chronic pain for which there apparently is no cure. We may
however ask if it is possible for people with chronic pain to
improve their condition without support from health profes-
sionals. This may seem particularly difficult because chronic pain
is a contested illness, and thus, as demonstrated in our findings,
people suffering from these kinds of symptoms often have very
little social support from others, such as family, colleagues and
friends. Thus, with regard to further restitution, women suffering
from chronic pain risk being left completely alone in this work.
Regarding the chaos that appeared in the beginning of the
women’s stories, we agree with Frank who emphasizes the
challenges of hearing these stories [14]. This is because chaos
narratives, by expressing despair and loss of hope, may provoke
fear in the listener by presenting a self that the listener does not
wish to become [14,47,48]. Consequently, chaos stories are more
likely than other narrative types to be ignored or disregarded by
those who are healthy. Health professionals, Frank claims, tend to
drag people out of their chaos stories, and rush them to move on
[14]. According to Mattingly, as cited in Smith and Sparks [47],
therapists and others work to construct ‘‘success’’ stories, ‘‘They
presume that patients will not be committed to therapy without
success, for success breeds hope, and hope is essential’’ [47].
Considering the delicate interplay of telling, hearing and honoring
stories, which indeed may be important with regard to making
progress the women’s stories of chaos, may too readily be
replaced by an institutional ‘‘success’’ story, offered to them by
the health care workers. This means the transformation of the self
displayed in the patients stories may be presented too cleanly and
too completely, and additionally, depreciate those who fail to do
the same.
The men’s stories in this study that tend to claim a self
dissociated from the pain, resonate with other studies on gender
and health. Although the phenomenon is not only related to
gender, the split between body and mind appears to be more
articulated among men than women [49,50]. With respect to
men’s health, Connell points to how masculinity is tightly
connected to the men’s bodies [51], which makes disability a
direct threat to a man’s masculine identity. Connell claims that
one way for a man to deal with disability is to ‘‘reformulate the
definition of masculinity, bringing it closer to what is now
possible, though still pursuing masculine themes such as
independence and control’’ [51]. In terms of the men’s stories
presented in our study, expressions like ‘‘standing at a cross-
roads’’ and ‘‘scaling back my workload’’ may represent a
reformulation of masculinity, in such a way that independence
and control can still be claimed. However, it may be essential
for men suffering from chronic pain to have a disease, represented
by a bio-medical diagnosis, in order to reconstruct their story
of self and move on in life [13]. Accordingly, if they have no
prospect of any such diagnosis, then claiming an active rehabili-
tative self may be one way for men who are disabled by
chronic pain to reformulate their masculinity. This presumption is
 DOI: 10.3109/09638288.2013.793750
supported by the study of O’Brien et al. [13]. Although the men
in that study generally reported a reluctance to seek medical
care, some of the men embraced medical care when they
perceived it as a means of preserving or restoring another more
valued enactment of their masculinity (e.g. working as a fire-
fighter, or maintaining sexual performance or function). With
regard to the men in our study, being disabled because of a
pain nobody believes in may represent a larger threat to their
self images than being in a dependent relationship to health care
services.
When it comes to the men’s stories that claim to have a self
continuously embedded in a restitution narrative, they demon-
strate some similarities to the stories of men who have become
disabled due to a spinal cord injury [47]. Investigations into those
stories show that, as in our study, most of the men’s experiences
were shaped by the restitution narrative. Most interesting to us,
however, is the question of whether this narrative type, which
implies a special kind of hope, is important to the men
Disabil Rehabil Downloaded from informahealthcare.com by University of North Carolina on 05/30/13
themselves, or if the men’s narratives are stories they feel they
are supposed to tell under the specific circumstances. Importantly,
in constructing their illness stories, ill people take care of
themselves, but as storytellers they also care for others, namely,
the listeners [14]. Thus, the men’s restitution narratives, which
are the kind of narratives most people want to hear, may, like the
women’s narrative, be inflicted by a human urge for social
acceptance. However, if this means a holding back of subjective
experiences of suffering and vulnerability, as suggested in our
findings, the result may also be that men with chronic pain are not
met or treated in the best possible way by health professionals.
This dilemma has been discussed in greater detail in a previous
For personal use only.
study [52].
With regard to the limitations of the study, we acknowledge
that the stories these men and women told us in the interview
context are influenced and shaped by what is possible in the
relationship between the teller’s active construction of a self, and
the social circumstances that enable and constrain these stories
[29]. As most of the interviews took place at the rehabilitation
clinic, the men’s and women’s stories are probably strongly
influenced by common stories that are circulating at the
rehabilitation clinic. We do not, however, claim our findings to
exhaust the possibilities of stories narrated by men and women in
rehabilitation because of chronic pain. Rather, in line with many
contemporary narrative researchers we understand the stories
represented in our findings as one possibility in a range of many
[29]. Moreover, as dynamic constructions, the stories people tell
about their self continue to develop as they move on and gain new
experiences in life, and as such the stories change with each
telling. Nevertheless, we believe our study makes important
contribution to a more nuanced understanding of how gender
appears in the stories of self, told by men and women with chronic
pain in a rehabilitation context.
Implication for practice
Chronic pain and disability may significantly change the
relationship between the ill person’s self and other people [53].
The ill person loses some of their ability to function socially and
professionally, they feel they are no longer what they used to be.
In this respect, constructing an illness story, and a continuity
between the self one used to be and the self one may become, is a
mean for the ill person to restore meaning in life and cope with
illness [54]. Our findings demonstrate how gender may appear in
stories of selves narrated by men and women with chronic pain.
Understanding how gender intersects with stories of chronic
pain may be of great significance to the professional’s ability to
acknowledge the tellers’ health problem, and importantly, to the
(Un)doing gender in a rehabilitation context 7
medical treatment given to these patients, which is important with
regard to their ability to move on in life. A broader understanding
of the meaning of illness in the individual’s life, as well as the
significance of gender in illness stories, may help to improve the
health care to men and women living with chronic pain.
Acknowledgements
We wish to thank the informants for sharing their stories with us,
and the physiotherapists for their assistance to recruit participants
to the study.
Declaration of interest
The project was funded by the Norwegian Fund for Postgraduate
Training in Physiotherapy. The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of this article.
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