As I mentioned yesterday, finding research articles on goal-setting in chronic pain is not easy – there are not many out there! So this article is reasonably old, but an interesting one because it deals with something I’ve wondered about for a while: flexibility. To be flexible doesn’t just mean being able to touch your toes! it does mean being able to change tactics, direction and even focus in order to achieve fulfilment in life.
This study looks at the difference between assimilative coping: ‘active attempts to alter unsatisfactory life circumstances and situational constraints in accordance with personal preferences’ and accommodative coping: ‘revising self-evaluative and personal goal standards in accordance with perceived deficits and losses’.
We have a good body of research that suggests ‘active coping’ is better for people seeking treatment for chronic pain (e.g. Jensen et al., 1991), but coping isn’t well defined, and there doesn’t seem to be a good theoretical model that most people can agree on. Coping strategies haven’t been derived from people who don’t seek treatment (and therefore cope well) use for their pain, and most coping assessment measures don’t recognise that what may be helpful in one situation may not be in another.
So this study was based instead on Brandtstadter’s (from the University of Trier) work on developmental problems and role transitions in adult life, where he studied assimilative and accommodative modes of coping.
As I described yesterday, goals are developed from a discrepancy between what is and what the individual would like to see happen. These discrepancies are often instigated by the individual, but can also be triggered by a change in the context, environment or demands from another person. Coping refers to efforts an individual takes to achieve – neutralise a threat or avoid loss, or perhaps achieve a success.
Brandtstadter identified that assimilative coping strategies involve altering the situation – for example, asking another person to help, using gadgets, or developing new skills based on feedback, changing the way an activity is done. Accommodative coping strategies involve altering expectations – changing desires or preferences, perhaps changing the expected outcome, giving up ideals (working to 100% for example), or even comparing how the person is going with other people who are more disabled.
The researchers in this paper identified that a ‘healthy pain patient’ is someone who is managing their pain in a way that ensures he or she has good quality of life, and feels well, and this probably requires the person to make ‘accommodative adjustments’ to existing goals and standards.
The recruits in this study were 120 people receiving inpatient treatment at a facility in Germany. More women than men were recruited, and most were married. The average pain duration was 11 years, and half of the participants had been away from work, and of that group, 40% had been so for at least 6 months. Most of the patients had headache (40%) while the remainder had low back pain, whole body pain, or pain in other sites as well as headahce.
The participants were assessed using the Pain Disablity Index (Tait et al, 1990), and the mean score in this study was 31.67 (SD=15.71). Psychological distress was measured using the CES-D, with a mean of 19.65 (SD=10.60), meaning that 53% of this group scored at or above the cut-off score usually used in the German version of this questionnaire. 24% of the respondents were diagnosed with an affective disorder using the Structured Clinical Interview for Diagnosis (SCID).
In terms of pain coping, three cognitive and three behavioural aspects of coping were assessed using likert-type scales from 1 (not at all true) to 6 (absolutely true). Finally, ‘dispositional coping tendencies’ following the Brandtstadter model were assessed using a questionnaire developed by Brandtstadter & Renner (1990). Two scales are formed by the questionnaire: ‘flexible goal adjustment’ such as ‘I adapt quite easily to changes in plans’ and ‘I find it easy to see something positive even in a serious event’; and ‘tenacious goal pursuit’, such as ‘when faced with obstacles, I usually double my efforts’, and ‘even when things seem hopeless, I keep on fighting to reach my goals’.
What did they find out?
Coping and pain intensity weren’t correlated, but a negative relationship was found between disability and distraction. Cognitive restructuring and self-efficacy were strongly associated with less depression. Both ‘flexible goal adjustment’ and ‘tenacious goal pursuit’ were negatively correlated with depression, although flexible goal adjustment had a stronger relationship than tenacious goal pursuit.
With further multiple regression analyses, it was found that flexible goals adjustment played a protective role when pain intensity and disability were high – that is, the ability to adjust goals flexibly seems to be a resource which ‘buffers the negative effect of chronic pain on psychological well-being’. This same positive relationship wasn’t found for people who continued to pursue their original goals by working harder.
The authors finally conclude that pain-related coping is only adaptive (that is, reduces pain severity or perceived disability) when the person has both ‘an accepting attitude’ towards chronic pain and uses positive coping strategies. In saying this, Schmitz, Saile & Nilges make a point that today has been empirically studied by researchers such as Lance McCracken and Kevin Vowles at Bath University: accepting chronic pain makes a difference to how well a person copes with ongoing disability.
A final point to make about this study – of the cognitive coping strategies, cognitive restructuring was the only strategy that moderated the relationship between depression and disability. Cognitive restructuring involves things like positively reinterpreting pain, reducing pain’s significance, or directly accepting pain.
Some cautions to consider when interpreting this study: it is a correlational study, so can’t demonstrate cause and effect. It’s also in a small group of people presenting to a specialised pain management centre. To date, it seems to be only study on this type of coping in people with chronic pain.
Food for thought from this study, however. Goals are all about achieving things. For some people, as I mentioned yesterday, having high goals and feeling dissatisfied with the ‘way things are’ can be a way of life that has helped them succeed. When chronic pain is present, this style of coping can become unhelpful – and it will be important to identify other ways for the person to retain their sense of self efficacy and achievement.
I think that identifying ‘different’ ways to act according to values that are important is one way to help someone live well despite their disability. This suggests that Acceptance and Commitment Therapy (ACT) may be an appropriate approach especially for people who have previously been high achievers. On the other hand, helping people who have lowered their expectations to re-set their ‘satisfaction’ set-point might involve helping them recruit new and different strategies to improve their ability to commit to ‘tenacious goal pursuit’.
Next post: another study on goals in chronic pain, and (with any luck) a worksheet!
Have a great day – and leave a comment if you’ve enjoyed this series, or have any questions.
Jensen, M., Turner, J., Romano, J., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain, 47, 249-283.
Schmitz, U., Saile, H., Nilges, P. (1996). Coping with chronic pain: flexible goal adjustment as an interactio buffer against pain-related distress. Pain, 67, 41-51.