One half of knowing what you want is knowing what you must give up before you get it. ~Sidney HowardMany are stubborn in pursuit of the path they have chosen, few in pursuit of the goal. ~Friedrich Wilhelm Nietzsche
There are few topics closer to my heart than goals. This is partly because of my background in occupational therapy, where goals are seen as part of how we live purposeful, meaningful lives – but it’s also because they’re incredibly difficult to help others to do, yet goal setting is seen as integral to therapy.
I’ve also been considering the whole topic of coping recently. What is coping? Which coping strategies are helpful? Is it possible to view coping efforts without also looking at the context in which they’re being used? My current conclusion is that, at least in pain management, coping is a concept that we really haven’t come to grips with. Even the term ‘coping’ isn’t well-defined: is it the process of adapting to a situation? the outcome? or the strategy employed?
Karsdorp and Vlaeyen, in this pre-print article, consider the pursuit of goals as part of the problem of disability associated with chronic pain. What? you say – how can going after a goal be part of the problem? Let me explain.
For some time, we’ve recognised that along with the people who avoid activity and become deactivated and highly disabled, there is a somewhat smaller number of people who superficially seem to be coping well – they’re active, maintain going to work, keep the family going and so on, but at the same time can be highly distressed by their pain. Their pain represents a roadblock that gets in the way of getting things done, but unlike the first group who stop doing and avoid experiencing pain, this group of people seem to almost redouble their efforts. They just keep going.
One model looking at mood and the motivational effects of mood is the “mood as input” model. This model proposes that “the motivational effect of goal pursuit on behavior is moderated by mood”. It suggests there are two types of goal – short-term ‘hedonistic’ goals, and long-term ‘achievement’ goals. Hedonistic goals are all about pleasure in the ‘now’ – that taste of chocolate, the joy of running and so on. Achievement goals require a longer-term focus and may involve some hard work in the short-term – learning to ride a bicycle, drive a car, win a race.
In this model, the degree to which a person tends towards either type of goal is thought to be influenced by mood. In other words, negative mood suggests to the individual trying to achieve a goal that they haven’t got there yet – leading to task persistence. In other individuals, negative mood suggests that they’re not enjoying the goal any more, so they should stop. Of course, most of us have a mixture of goals, both hedonistic and achievement, but there does seem to be a tendency towards one type or another in some individuals, and in this study by Karsdorp and Vlaeyen, it was hypothesised that those with a strong preference towards one or the other, would present with the most disability and pain, dependent on their level of negative affect.
Nearly 300 people with current pain present in any part of the body and with various diagnoses were recruited by newspaper for this study. A large battery of questionnaires were completed including some related to goals, affect, catastrophising, perfectionism and pain-related disability. Using exploratory factor analysis, a two-factor structure was obtained from the data – one factor related to pain, and ‘the rest’. With the pain factor excluded, a further two factors were obtained – one related to a pain avoidance goal, and the other to a mood management goal.
After completing further analyses, mainly multiple regressions, a nonlinear, U-shaped association was found between
pain-avoidance and pain and disability. What this means is that a stronger endorsement of either pain-avoidance goals or achievement goals was related to greater pain and disability while controlling for other factors.
The other main finding from this study is to confirm previous research that has found an association between high “sense of responsibility” and achievement goals and between pain catastrophizing and the “hedonic” goal to find a solution for pain. In other words, there are some people who push themselves to complete goals because of a high sense of responsibility and the negative emotions they experience when they don’t complete things to their satisfaction – and in this group, disability and distress is increased when their pain ‘gets in the way of’ achieving these goals. Then there are other people who tend towards primarily trying to manage their mood, who are likely to catastrophise more about pain, and are more inclined to avoid activities that exacerbate their pain.
Now here is where I think we need to do more research. Rather than classifying coping strategies according to ’emotion-focused’ or ‘solution-focused’, or ‘active’ vs ‘passive’, I think we need to look at the function of coping strategies as they are conducted in the pursuit of things people want to do. It’s not helpful to see people as separate from the context of what they want to do, and where they want to do it.
This model is in its early stages, the findings were relatively weak, and there is clearly much more to be done to explore the idea of goal pursuit and coping strategies, but it is nice to see that at least one group of researchers is concerned about “why” people do things as much as “what” they do.
Karsdorp, P., & Vlaeyen, J. (2011). Goals matter: Both achievement and pain-avoidance goals are associated with pain severity and disability in patients with low back and upper extremity pain PAIN DOI: 10.1016/j.pain.2011.02.018
HealthSkills Blog 
Oh, this is so good! I feel like someone suddenly validated my experience. Maybe it is because the “larger” number of people fall into the activity avoidance pattern, but this seemed to be the only pattern the doctors are primed to address. So almost every conversation goes along the lines “We have to get you active, and this will help your pain” – “Actually, I am active to the best of my ability [list the exercise that I do]” – “Then you are doing fine”. Really, for the majority of doctors I met the fact that I hold a job and am physically active equated with “she is coping well and does not need help”. In fact, they said so much: “You seem to be functioning on a very high level”, “You are coping much better than most patients we see”, “You don’t seem to be in that much pain”.
The reality of the situation is, I am living alone and without option from family help. So I feel very strongly about doing everything I can to keep my lifestyle in the sense of keeping my job and my independence, because I am not going to have much to fall back on in terms of help and care. And yes, I tend to have long-term goals and work for them. But this external “normalcy”, the fact that I still kept going to work despite fairly extreme pain levels, and that I used every bit of my time and project management skills (which are my primary value at my work, anyway) to keep myself going, seemed to hide and invalidate the real level of disability and distress, and degree to which with which even my best coping efforts were unraveling under the pressure of increasing pain.
I was lucky to eventually find someone who took me seriously, and also was able to give practical help. But doing this was difficult, and I still tense every time I need to see a new specialist and explain things to him/her. It is very reassuring to know that someone is recognizing that such situations exist and doing some research on them.
I think it reflects the ongoing nature of our research efforts to understand chronic pain. I’m particularly pleased to see that people are recognising that it’s not what you do but how that strategy functions that’s important. Good to see that they’re on the right track for describing someone in your situation too!
This was really food for thought for me to understand both myself and my pain as well as that of my patients. The psychological side of chronic pain often helps understand or question the why and something my psychologist once confirmed to me. the better one copes with their pain the harder it is for others to understand what you are going through and for me I must say this plays into my mood and I have my thoughts on why but it is a very interesting and complex construct. You can be cipoing outwardly and not so much within sometimes.
I think we all would like to have nice simple rules that are black and white – but as humans we’re just a bit too complicated for that! I’m glad I managed to provoke some thought. Faking ‘good’ is one part of living well with chronic pain, I think, but may not give sufficient voice to the part of you that would like acknowledgement of the difficulty of doing this.