Significant others are thought to have an influential role in the experience and progression of back pain, yet little research has thus far examined this role in the context of work participation. Findings from this exploratory study provide some potentially useful insights into the ways in which both individuals with persistent back pain and their significant others conceptualise and respond to back pain. The inclusion of significant others highlights some interesting and currently under-researched areas relating to wider social circumstances, which may play an important role in influencing occupational outcomes. It follows that these factors are potentially important in the design and implementation of occupational rehabilitation programmes.
There was a notable difference in the way that participants from the working and non-working samples described how the patient’s back condition had impacted on both the patient’s identity and on their activities. Significant others from the working sample tended to emphasise what the patient could do despite their condition and attributed this to the patient’s admirable personal characteristics, describing them as heroic and stoical. In contrast, our non-working sample emphasised the extent to which the condition prevented the patient doing things and descriptions of patient identity focused on the patient as a helpless victim, anticipating and rebuffing potential accusations of personal responsibility and blame. For significant others of patients out of work due a back problem, it may be that to justify the patient’s inability to continue in employment, it is necessary that they be defined in terms of their incapacity and in terms of their being ‘disabled’. This means emphasising what patients cannot do rather than what they can do, with potentially detrimental effects on their activity and identity. In the face of stigmatising socio-cultural beliefs about ‘benefit cheats’ and ‘malingering’ , significant others may feel they cannot allow room for scepticism to develop and it is therefore important that they support their ‘other’ by emphasising their inactivity and/or disability. This is likely to have negative consequences in terms of participation outcomes because activity avoidance is in direct opposition to the clinical guidelines for best practice management of persisting low back pain, which recommend that people with low back pain should be advised that staying physically active is likely to be beneficial .
Whilst work is generally good for health and wellbeing, there is a recognised social gradient in health partly dependent on the type of work . For participants in our ‘non-working’ sample, the nature of their previous roles could have limited scope for workplace adaptation, and it has been documented that particular difficulties exist in any return to work process after a period of ill health for individuals with lower levels of educational achievement and often physically demanding jobs [25, 33]. By contrast, our ‘working’ participants had higher status roles in which the work involved was described as more flexible, and participants had been able to negotiate their working hours and adaptations where they felt this necessary. Further examination of the data revealed that the working participants often felt it was a personal relationship with line management that had made these concessions possible, with Human Resource departments often described as less helpful and impersonal. These findings provide additional support for the notion that line managers have a key role in this context, which warrants further exploration to ensure that those undertaking this role have the necessary knowledge and support [34, 35]. Further research might also usefully focus on identifying how the design of interventions might assist in helping individuals stay economically active when the nature of a job role or business presents less obvious opportunities for redeployment or retraining. Whilst certain work may be perceived by both employer and employee as being limited in scope for adaptation, with some inventiveness in identifying and overcoming the pertinent obstacles, accommodations may in fact be possible . More recent work emerging from the body of literature on organisation culture and reflecting on how workplaces can best foster a supportive culture to overcome workplace obstacles may be useful in this respect . Others have highlighted the importance of making sure that employees are fully informed about their rights and responsibilities in the context of musculoskeletal pain conditions  and the present study lends further weight to this call.
Our findings suggest that patients will encounter a range of psychosocial obstacles to work participation and there is a danger both they and their significant others will perceive these obstacles as insurmountable especially in the face of socio-cultural scepticism about their condition, along with widespread disparagement of the unemployed. Many disadvantaged individuals become entrenched in a position whereby it becomes all the more important to be seen as completely disabled. In adopting this stance and limiting their activity, the chances of any return to work and economic activity become increasingly remote. Importantly, our research suggests that well-intentioned support from those close to patients may be serving only to further entrench this position of total disability, adding to the body of previous evidence which demonstrates how solicitous responding by others to pain related behaviours can be associated with a range of negative outcomes . Thus, the role of significant others may warrant further investigation by those looking to facilitate effective vocational rehabilitation. This is especially important in light of the on-going changes to the welfare system in the United Kingdom, which are being implemented to reduce its substantial cost burden, as it raises the possibility that initiatives will be interpreted as removal of support, being linked to and allied with punitive measures. Our findings suggest that it is possible that, where individuals are faced with more stringent tests and assessments to determine their eligibility for benefits, this may encourage further efforts by patients and those close to them to demonstrate the (perceived) severity and impact of the illness, thus entrenching attitudes and leading to further inactivity.
However, our findings also demonstrate that significant others are clearly important sources of support to individuals with back pain, and their inclusion in any such rehabilitation and education programmes could potentially be a valuable way of mobilising readily accessible resources in a way that supports optimal functioning. Indeed, it has been suggested that a ‘can do’ focus may be associated with better functioning in terms of work participation outcomes . This approach is in line with current UK government policy and the introduction of the Statement of Fitness for Work (the fit note –http://www.dwp.gov.uk/fitnote) by the Department for Work and Pensions in April 2010. This replaced the previous Medical Statement (the sick note), and changed the focus firmly to what people can do despite their health problem, as opposed to emphasising (and certifying) what they cannot do.
It is acknowledged that a limitation of this study is the small sample of people with back pain, all recruited from one geographical area in the United Kingdom. Additionally, we recognise that the different social welfare arrangements in place in the different countries of the developed world may well impact on the extent to which these findings can be generalised to other international settings. Nevertheless, our use of in-depth qualitative research methods provides novel and potentially useful data on which further work can build. Many of our findings support and extend previous findings from work with long-term welfare claimants and further research focusing on individuals recruited from primary care settings may offer additional insight into the disability trajectory, identifying at what point interventions focused on significant others may be most valuable. Future research might also usefully explore in more depth the relative importance on the specific dimensions delineated in this study. This study cannot offer a perspective of those who report having no significant other, and we did not examine in any depth differences between significant other type. Whilst living on one’s own does not necessarily mean that one has no significant other support, it may be that there are differences worth examining between dyads based on whether or not they co-habit, and it might also be useful to explore different types of significant other (for example parent/ child dyads in comparison to spousal dyads).