Some of you will know I’ve been striving to write my PhD proposal lately, ending up with loads more words than actually necessary! However, as part of it I’ve been reviewing some of the material I’ve collected over time on coping.
Coping is one of those difficult words – one we all know, but don’t always define especially well. One definition of coping is ‘purposeful efforts to manage the negative impact of stress’ – this one’s by Lazarus & Folkman. This definition suggests that coping involves active choices about what to do in the face of stress.
Wikipedia (o font of all knowledge) defines coping as ‘managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict’. Again this definition suggests it’s something about effort or mastery – but adds ‘tolerate’ as a final option.
There are literally hundreds of ways to ‘cope’ with something that demands a response from you. The way you cope depends a lot on how you view the stressor: it could be seen as a challenge ‘Oh wow! This is something I have to beat’…it could be seen as a threat ‘Oh no! This will be way too difficult to manage’… or it could be seen as something to accept ‘Oh well, that’s the way the cookie crumbles’.
Most people flip between these different ways of coping, and the workability of each approach depends a lot on the type of stressor.
In the case of short-term stressors, like a flare-up or an acute pain that you know will soon go, maybe viewing it as a challenge or a threat may be helpful. It may mobilise energy (through the stress response), it may help with taking action in the immediate situation. But – it won’t help over the longer term, especially if the problem is something that won’t change or be ‘beaten’ by being treated either as a challenge or a threat. Chronic pain is one such stressor that these two coping strategies don’t seem to work too well on.
Some cognitive therapists suggest that by changing our appraisal of pain from ‘threat’ to ‘challenge’ we can change our view of the problem, and by reducing the ‘threat value’ of pain, our perception of pain can similarly change. I agree – to a certain extent. I’ve heard some therapists, following a ‘logical’ argument, say that once someone’s been ‘educated’ about pain, the threat value of pain is inevitably reduced – and eventually, once the brain is retrained, the pain itself will actually reduce. I’m not entirely convinced of this. When I take my fibromyalgia as a case example, I’m fully aware that my pain does not equal harm, it’s not a threat to me. It’s still sore. It still can interfere with what I want to do. And by viewing it as a ‘challenge’ I can sometimes push myself to beyond what is healthy for me. On the other hand, to view my pain as a threat wouldn’t be helpful either: I’d be beaten before I’d even started!
So I view my pain differently. I see the final coping strategy as acceptance. It’s not an easy road. It’s very difficult to stop fighting against something that interferes with what you want to do. But it’s reality – pain doesn’t just stop because you want it to, or because you know it’s not harming you. It just is.
I use a lot of metaphors when I’m talking about chronic pain. One image I like with acceptance is moving from a fight (having to ‘beat’ the pain, not letting pain ‘beat’ me, overcoming pain) to a dance – where pain becomes a partner. Sometimes I’m ‘leading’ and moving in the direction I want to, sometimes pain takes a few spins where it dominates. It looks like pain might be leading – but in the end, I’m the main determinant of the style of dance, of the speed and pace of the dance, and I set the music. I also decide the direction I go in!
Another metaphor is the squatter. Pain is a squatter that can move in, uninvited. It can, if given half a chance, sit itself down in my kitchen, take over my bed at night, sit on my lap when I watch TV, and even get between me and my partner. Or I can gently, but firmly, move pain out of the lounge, into the back room, perhaps even out of the house and into the garden shed. I may never completely be rid of pain – but I can stop pain from interfering with my home and work.
And a final metaphor is pain as a hitch-hiker. Pain can hitch a ride in my car. Once again, it might try to sit on my lap, even take over the wheel at times. I may not get rid of pain, but I can take over the steering wheel, I can put it into the back seat or the boot (trunk to you North American’s!). I get to decide where I go, when I go, how fast I go and when I stop.
Acceptance involves a whole bunch of coping strategies. Some of them are ‘active’ – people can break activities into smaller pieces, or a alternate between different tasks, they can start at a low level, but gradually increase. They can be less active also – using heat, medication, relaxation strategies. Whatever allows the person to continue with activities but allow pain to be present at the same time as doing the activity.
ACT, or Acceptance and Commitment Therapy, involves using this last approach to living with pain. By removing the ‘judgement’ about the meaning of pain, it is possible to reduce some of the distress that comes from having it interfere with activities.
I’m reminded again of something I read recently:Pain for Philosophers posted about the difference between ‘ameliorating’ and ‘obliterating’. The point was well made (take a good look at the post to see what I mean), but the part I want to highlight is this –
It is a serious conceptual mistake to think of a patient who feels helpless and resigned in the face of her pain as (necessarily) being in two bad states:
(a) Her pain is bad to degree x
(b) Feeling helpless and resigned is bad to degree y.
Rather, these feelings are themselves parts of the pain. Their treatment is just as much a treatment of the pain itself as is the administration of morphine.
Why this is important is that I think ACT helps with (b). I’d change (a) to be ‘sensations’ of X intensity, while (b) relates to the judgements made about the meaning of pain.