I’ve been pondering, as I do when writing my PhD, about the ways we have studied ‘coping’ in chronic pain. It’s like researchers have conceptualised coping as a static trait rather than a developmental journey, and this is something I’m struggling to accept.
Definitions of coping have emphasised that coping consists of ‘purposeful efforts to manage the negative impacts of stress’ (Lazarus & Folkman), and my guess is that many factors influence the choice of specific strategy. Some that spring to mind are:
- how the event is construed – is it ‘stressful’, is it negative, is it thought to be short-term etc
- how meaningful the negative impacts are on the individual
- how much energy/resource the person has to use to cope
- how comfortable the person is with using coping strategies (what are their cognitions about using these strategies?)
- how other people and systems around them respond to their coping efforts
- their developmental stage (child vs adult)
- how well-rehearsed coping strategies are (can they think of them when they need them?)
OK, so these thoughts are not new, most of these aspects of coping have been considered over the course of the last 25 – 30 years. Some aspects, however, have not. One that really strikes me is the context or the activities the person is wanting to do (how important activity X is over activity Y) – I can certainly find ways to cope with my pain when I want to go clothes shopping, but ask me to do the vacuum cleaning, and it’s another whole different ball game! This aspect of coping has been looked at only a little (here’s a post I wrote on one paper that does deal with this).
Another is the ways in which coping is refined over the lifetime of a pain problem. I’m often reminding students that people with persistent pain started with acute pain at some point. When we get acute pain we do things that we hope will reduce the pain and allow the area to settle down. The efforts people make to find a diagnosis, find a cure, avoid ‘damaging’ the area and so on are normal and develop from our expectations that hurt does equal harm, at least in the beginning.
Over time, however, when it becomes clearer that chronic pain is not going away, I’m sure that at least for some people, coping changes. When it doesn’t change, then we run into the ongoing disability problem that is, I think, the REAL problem of chronic pain.
So, in people who generally cope well with their persistent pain, and maintain work, life, relationships, fun and so on, I think coping strategies develop and evolve over time.
In people who don’t manage so well, at least one aspect could be the lack of ongoing evolution of coping that allows the person to re-engage in life. Perhaps part of this inflexibility is having to change expectations about what a person can or cannot do (assimilative goal setting). Perhaps another part is the inner debate about whether it’s OK to ‘do things differently’. Something else might be about reconceptualising from being ‘disabled’ or a ‘sufferer’ to being a person who happens to have pain.
I also wonder whether getting to the point where coping strategies become habitual, or ‘this is how I do this’ is something that researchers haven’t looked at too often. Once coping strategies become habitual, it’s a lot harder to recall exactly what is being done. The habits become ingrained precisely so that we don’t have to think about them, and in so doing, reduce the cognitive demands of daily life. The problem with this for researchers is that it becomes a lot more difficult to study, because people don’t bring their coping strategies to mind as easily.
Over the lifetime of chronic pain, my hunch is that coping strategies change. Not only do some ways of coping become easier, others become redundant because they don’t work, and others are adapted and transformed. I think the strategies most likely to become adapted and transformed might be the cognitive ones, or the beliefs and expectations about what gets done, and how it gets done. These beliefs and expectations develop from our underlying values – and maybe that’s something that changes over time too.
Another way of looking at coping is to consider motivation – read this paper if you can, because it suggests that putting ways of coping into a motivational framework helps both identify what is ‘working’ and what isn’t, but also helps engage the person with the pain to look at what is missing in their life as a result of their current coping strategy. And helping people to do what is important and has value is surely my purpose in clinical work.
Van Damme, S., Crombez, G., & Eccleston, C. (2008). Coping with pain: A motivational perspective Pain, 139 (1), 1-4 DOI: 10.1016/j.pain.2008.07.022