After yesterdays’ post on coping and motivation, I’ve been pondering how we classify coping into ‘good’ and ‘not so good’. And what pain management is really doing by helping people develop new ways of coping, as if their old ways were ‘bad’. And feeling a bit of a fraud actually because when I’m working with people I do say ‘what you’ve done in the past has worked at least once’, so I do believe that people make the best decisions at the time, given the resources they have.
Today I want to go into this article a bit more, but at the same time reflect on coping as I see it.
Van Damme, Crombez and Eccleston propose that coping be classified not according to external features (eg active vs passive), but rather into function – what the coping does, how it functions in context. These authors refer to the Brandtstadter and Rothermund model of goal-directed coping – assimilative in which people try to work out how to achieve the goal despite barriers, and accommodative in which people adjust their expectations about their goals in order to reduce the internal tension they experience from striving for the unattainable.
To quote directly from the article,
“Coping with chronic pain is recast as attempts to pursue
valued activities and life goals. Starting with interruption
of ongoing behaviour by pain, individuals appraise
the importance of the interrupted activity and the nature
of the obstacle.When the blocked goal is important, individuals
may simply try to ignore pain and try harder to
accomplish their task (task persistence). In other situations,
searching for a solution to pain may become a salient
This is exactly what I’ve found clinically – people try over and again to ‘find the cure’ or ‘fix the problem’ and this becomes their goal rather than other valued goals in their life. Alternatively, they find a multitude of creative ways to achieve their goals despite their pain – such as ‘boom and bust’ patterns of activity, delegating others to do the job, using gadgets – you’ve probably seen the lot as well! When people don’t achieve their goals they may give up and become depressed, demoralised, disillusioned. The process of coming to terms with the inability to ‘fix the problem’ and return to ‘life as normal’ is often the point at which therapists are called in (after the person has given up a biomedical approach).
My job is often about helping people come to terms with change – again I have to quote directly from this paper:
An ‘accommodative route’ is
characterized by a reappraisal of (blocked) goals.
Patients may devalue the importance of the blocked
goal for their life, or may find more value in the pursuit
of life goals that are less affected by pain. Indeed,
both attempts at disengaging from unattainable goals
and attempts at engaging in new goals have been
shown to be beneficial for the well-being and quality
of life in the context of coping with physical illness.
Possible responses are acceptance, priority setting,
and cognitive restructuring.
So it seems that either option can be ‘the right one’ for a person. And coping efforts are aimed either at achieving the goal, or coming to terms with being unable to achieve the goal in the same way as before pain.
It seems to me that much of the work of pain management is not to show people ‘the right way’ to cope, but instead to extend their repertoire of coping strategies. This means they can choose the best approach for the specific situation they’re in. To be thoughtful about why they are choosing a particular strategy, and to be fully aware of the short term effect and the long term effect of using any way of coping.
As I say to people ‘what you’ve done to cope has worked at least once’ – but I also add ‘but sometimes has unintended consequences’. It’s important to help people become aware of the effect of their choices – then leave them to make their own choice. Too often I think we can be quite judgemental about people’s coping choices, and try hard to ‘make’ someone do their own life differently. We will only experience dismal failure if we try this!
I’ll post on this article again tomorrow, because the conclusions are really pretty profound. If people are trying to cope with pain, it’s to achieve an end – a life that they feel is worth living. And lives that are worth living involves being able to achieve the things that particular person wants to achieve. And that is a very individual thing.
Van Damme, S., Crombez G., Eccleston, C., (2008) Coping with pain: A motivational perspective, Pain, doi:10.1016/j.pain.2008.07.022
S DAMME, G CROMBEZ, C ECCLESTON (2008). Coping with pain: A motivational perspective Pain DOI: 10.1016/j.pain.2008.07.022