Recently, I’ve been reviewing the whole concept of coping in chronic pain. I’m trying to establish how people with chronic pain view this term, and what they include in their repertoire of ways to cope. My research is looking at the ways that people who cope well with their pain, and never need input from a chronic pain management team, do so. And in doing this research, I’m hitting some conceptual snags.
The thing is, coping as a concept isn’t defined all that well. Some definitions refer to the outcome of coping: “he coped well with that” meaning “he managed that stressor in a positive way and the outcome was good”; some definitions refer to the process of coping and don’t consider the outcome at all: “she is coping with a lot of concerns at the moment” meaning “she is going through a process of managing a large number of stressors” – but make no reference to what happened as a result of that process.
Coping can mean “anything that’s done in response to a threat”. When it’s used in this sense about pain, it can include both automatic responses like physiological arousal and flinching, as well as intentional responses like resting, stretching or going to a doctor.
Coping can also be more narrowly defined and mean “intentional responses to a stressor”, in other words, things that need effort and are thought about. This latter definition was developed by Lazarus and Folkman (1984), and introduced some helpful theoretical concepts that informed research on the ways people adapt to stressors.
The way that Lazarus and Folkman conceptualise ‘coping’ has influenced the research into ways people manage the effect of chronic pain – this model describes ‘cognitive appraisals’, or the ways in which people view the stressor as being either a challenge, or a threat. If someone sees pain as a threat, it magnifies the view of pain as a potential for harm or loss and produces a negative emotional response, which is closely related to vulnerability and has been shown to lead to ’emotion-focused coping’, whereas if someone sees pain as a challenge, it can lead to ‘problem-focused’ coping (Dysvik, Natvig, Eikeland & Linstrom, 2005).
There are other ways to explore the idea of coping – here’s a few:
Some research has identified a distinction between ‘active’ coping and ‘passive’ coping. Active coping refers to ways of coping that focus on trying to control pain or to function despite pain, while passive ways of coping refers to withdrawing and surrendering control over pain. Active coping strategies can include things like distraction or activity management (pacing), while passive coping can include things like rest or avoidance (Brown and Nicassio, 1987).
Another distinction may be drawn between ‘approach’ and ‘avoidance’. Approach coping means engaging with the pain and its causes (such as trying to work out the triggers for flare-ups or seeking treatment), while avoidance coping involves strategies of engaging efforts away from pain (such as ignoring the pain, or attempting to avoid increasing pain) (Reid, Golbert & McGrath, 1998).
I have some trouble with what I’ve read so far about coping. Some of the difficulties I see with distinctions like the ones above is that they don’t consider the context or the purpose (function) of certain strategies. For example, there are times when it’s OK to push beyond ‘usual’ functional limits to achieve certain goals instead of pacing, or spreading activities out over a day (it’s really hard to stop in the middle of baking a sponge cake to ‘pace’!), and it’s quite common for people to be prepared to persevere at a sporting activity even though it increases pain because of the benefits experienced in terms of mood or experiences of achievement.
It’s also not clear whether people use the same strategies for the same reasons as they progress through the lifetime of their pain problem. It might make sense to use medications in the earlier stages of a pain problem, but to choose not to continue with these later on. Selective use of rest may be appropriate during the early stages of coping with rheumatoid arthritis but less sense as time goes on.
And to add fuel to my doubts about coping strategies, I’m not sure that what we teach to people who want help with pain management is what people who don’t seek help actually use. We may be trying to teach people things that don’t integrate well with everyday life. Certainly there’s evidence that 12 months after completing a programme, these coping strategies are often not used – but reduced disability and distress achieved soon after a programme is maintained despite this finding (Curran, Williams & Potts, 2009).
My final muttering about coping strategies is that some of them don’t work – or at least, don’t work in the way that they’re intended to. For example, it’s not really possible to control pain – there are many times when, despite the best efforts of people to follow activity management principles and to manage stressors and to think in helpful ways, pain fluctuates. By focusing on efforts to change the pain, we can encourage people to constantly analyse what they’ve ‘done wrong’ to flare their pain up. By focusing on trying to change thinking, we can lead people to judge themselves harshly for having the same sort of thoughts that we all do – these thoughts still occur, it’s really more important to work out how much attention to pay to thoughts, and how to learn to let them go in order to focus on what the person wants to do.
I’m not saying we shouldn’t help people develop a wider range of coping strategies – but I am suggesting that we now need to do some more work to understand the function of various types of strategy, when they might be helpful or useful (and when they might not be), and I think simplistic dichotomous classification of strategies need to go. We might consider studying people who cope well with pain – and identifying the strategies that these people use (and when). We might think about helping people recognise the short-term and longer-term consequences of various strategies.
Most importantly, I think we need to learn to work with people to identify whether the coping strategies they already know and use are helping them live out the values they prefer. This approach isn’t my own invention, btw, it’s a basic tenet of Acceptance and Commitment Therapy where the main question to ask is ‘how well is this working for you?’
Maybe, as I suspect, we don’t need to focus as much on helping people learn new coping strategies, but instead focus on how to help people identify what is important to them, and how they can get there.
Brown GK, Nicassio PM. (1987) Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain. 31:53–64.
Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.
Lazarus RS, Folkman S. (1984) Stress, appraisal and coping. New York: Springer Publishing Company.
Reid GJ, Golbert CA, McGrath PJ. (1998) The pain coping questionnaire: preliminary validation. Pain. 76:83–96.
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